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DISEASES 

OF THE 

DIGESTIVE ORGANS 

IN 

INFANCY AND CHILDHOOD. 



STARR 



By DR. LOUIS STARK. 



THE HYGIENE of the NURSERY 

INCLUDING THE GENERAL RBGIMBN AM) REEDING 01 

INFANTS am> I HILDRBM AM) THE DOMESTIC 
MANAGEMENT OF THE ORDINARY BMBR- 

C.l NCI I S OF F.AKI V 1 III. 

Second Edition. Enlarged and Improved. 

WITH TWENTY-FIVE ILLUSTRATIONS. 
12mo. 280 Pages. Cloth, $1.00. 



*#* Designed for the use of Parents, Nurses, and all 
interested in the Care and Management of Children. 

" The volume is entirely in the modern lines of preventive medi- 
cine — more important in the nursery than in any other time of life ; 
because constitution building is going on then and there. Jn this 
admirable treatise, so clearly written that no mother need be de- 
terred by fear of medical terms from making its teaching her own, 
Dr. Starr carries out the highest ideal of the modern physician, so 
to regulate the lives of his professional clients that the occasions 
are less frequent when he need be called in to act for serious com- 
plications * * * * With the numerous good treatises on the 
subject that Philadelphia publications include, this intelligent work 
is the most distinguished, as it is also the latest work on complete 
Hygiene of the Nursery." — T/ie Ledger, Philadelphia. 

" It is addressed to mothers, with the view of giving a series of 
rules which, applied to the nursery, can hardly fail to maintain good 
health, give vigor to the frame, and so lessen susceptibility to dis- 
ease. These are so plainly, sensibly, and we may add attractively 
given, that any woman of ordinary brain-power should be able to 
understand them, and by following them to keep her baby well." 
The Critic, New York. 




Cmferit 



^4ll2huHe. Contoured. Neroes — Sf^Tair 
., Solid.£lcick. •■ =■ Sympathetic 

.. YeUo-to „ — fnrumxHjastric 

„ Bill? „ = 6lasso-Phfijyruf<>a.l. 



DIAGRAM ILLUSTRATING THE VARIOUS CONNECTIONS OF THE DENTAL NERVES. 

Plate 1. 



DISEASES 



OF THE 



DIGESTIVE ORGANS 



IN 



INFANCY AND CHILDHOOD. 



WITH 



CHAPTERS ON THE INVESTIGATION OF DISEASE; THE DIET 

AND GENERAL MANAGEMENT OF CHILDREN, 

AND MASSAGE IN PAEDIATRICS. 



BY 



LOUIS STARR, M.D., 



LATE CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNI- 
VERSITY OF PENNSYLVANIA ; PHYSICIAN TO THE CHILDREN'S HOSPITAL, 
PHILADELPHIA; CONSULTING PODIATRIST TO THE 
MATERNITY HOSPITAL, PHILADELPHIA, 
ETC., ETC. 



SECOND EDITION— ILLUSTRATED. 




PHILADELPHIA : 
P. BLAKISTON, SON & CO., 

No. 1012 Walnut Street. 
1891. 



Go 



Copyright, 1891, by Louis Starr, m.d. 



PRESS OF WM. F. FELL &. CO. 

1220-24 SANSON! STREET, 

PHILADELPHIA. 



TO 

PROFESSOR JOHN ASHHURST, Jr., M.D., 
THIS VOLUME IS DEDICATED, 

AS A 

Tribute to his Genius as a Surgeon and Author, 

and in 

Grateful Remembrance of 

Many Acts of Kindness. 



PREFACE TO THE SECOND EDITION. 



In preparing this issue of "The Diseases of the Digestive 
Organs in Infancy and Childhood," the author, while endeavor- 
ing to bring the general subject-matter thoroughly abreast with 
the times, has deemed it advisable to make some re-arrangement 
of the original text and to add a quantity of new material. The 
chief additions consist of a section on alterations in the odor 
of the breath in disease ; a section on urine alterations ; a chapter 
on massage in paediatrics, and a detailed account of second den- 
tition and its influence on the health in late childhood — a subject 
heretofore greatly neglected. 

The author wishes to thank the critics of the first edition of 
his book for many valuable suggestions, from which he has 
profited greatly. His thanks are also due to Dr. Wm. M. Powell 
for his untiring assistance in preparing the copy and in making 
the index ; to Dr. Robert J. Hess for his aid in proof-reading, 
and to Prof. Charles B. Nancrede for the diagram illustrating 
the extended connections of the dental nerves. 

LOUIS STARR. 

1818 South Ritlenhouse Square, Philadelphia. 
January 1st, 1891. 



Vll 



PREFACE TO THE FIRST EDITION 



It is the author's object, in this book, to give prominence to a 
class of disorders constituting a large proportion of the ailments 
of childhood, but often too briefly considered in works on 
paediatrics. For the successful treatment of the diseases of the 
digestive organs in infancy and childhood, attention to the 
general regimen is quite as important as the administration of 
drugs, and it is upon the former that the student and young 
practitioner are usually the least thoroughly instructed. 

So much may be done by the selection of suitable food, by 
artificial digestion, by regulating the clothing, bathing and other 
elements of hygiene, that the author, without neglecting thera- 
peutics, has given greater prominence to these points. 

The chapter on the investigation of disease does not neces- 
sarily belong to a work on disorders of the digestive organs, but 
as so much difficulty is experienced by students in the study of 
disease in children, it has been incorporated as an aid to such. 
In the article on the general management of children, the effort 
has been made to present to the inexperienced results that can 
only be obtained by much study and practical work. 

The author is indebted to Dr. Henry D. Harvey for his aid in 

preparing the index, and to the pencil of Dr. John Madison 

Taylor for the illustrations. 

LOUIS STARR. 

Philadelphia , April, 1886. 



Vlll 



CONTENTS 



PART I. 

Introduction — page 

The Investigation of Disease, 17 

1. Questioning the Attendants, 18 

2. Inspecting the Child, 20 

3. Physical Examination, 39 



PART II. 

The General Management of Children — 

1. Feeding, 60 

2. Bathing, 102 

3. Clothing, 105 

4. Sleep, 106 

5. Exercise, 108 



PART III. 
Massage in Pediatrics, 116 



PART IV. 

Diseases of the Digestive Organs. 

CHAPTER I. 

Affections of the Mouth and Throat, 1 24 

1. Catarrhal Stomatitis, 124 

2. Aphthous Stomatitis, I2 6 

3. Ulcerative Stomatitis, 13 * 

4. Gangrenous Stomatitis — Noma, 136 

ix 



CONTENTS. 

PAGE 

5. Parasitic Stomatitis — Thrush, 141 

6. Dentition, 148 

7. Simple Pharyngitis, , 183 

8. Superficial Catarrh of the Tonsils, 186 

9. Follicular Tonsillitis, , 187 

10. Suppurative Tonsillitis, 190 

11. Hypertrophy of the Tonsils, 194 

12. Retropharyngeal Abscess, 197 



CHAPTER II. 

Affections of the Stomach and Intestines, 199 

1. Acute Gastric Catarrh, 199 

2. Chronic Gastric Catarrh, 202 

3. Ulcer of the Stomach, 211 

4. Softening of the Stomach (Gastro-Malacia), 212 

5. Chronic Gastro-Intestinal Catarrh, 213 

6. Acute Intestinal Catarrh, 227 

7. Chronic Intestinal Catarrh — Chronic Entero- Colitis, .... 235 

8. Entero-Colitis, 248 

9. Cholera Infantum, 258 

10. Inflammation of the Colon and Rectum — Dysentery, . . . 264 

11. Tubercular Ulceration of the Intestines, 268 

12. Colic, 270 

13. Habitual Constipation, 273 

14. Simple Atrophy, 279 

15. Typhlitis and Perityphlitis, 287 

16. Intussusception, 296 

17. Intestinal Worms, 311 

CHAPTER III. 

Caseous Degeneration and Tuberculosis of the Mesenteric Glands — 

Tabes Mesenterica, 329 

CHAPTER IV. 

Affections of the Liver, 337 

1. Jaundice, 337 

2. Congestion of the Liver, 343 

3. Fatty Liver, 346 

4. Amyloid Liver, 347 



CONTENTS. XI 

PAGE 

5. Syphilitic Inflammation of the Liver, 351 

6. Cirrhosis of the Liver, 352 

7. Suppurative Hepatitis, 357 

CHAPTER V. 

Affections of the Peritoneum, 364 

1. Peritonitis, 364 

2. Tubercular Peritonitis, 371 

3. Ascites, , .... 377 

Index, 383 



DISEASES 



OF 



THE DIGESTIVE ORGANS 



INFANCY AND CHILDHOOD. 



PART I.— INTRODUCTION 



THE INVESTIGATION OF DISEASE. 

The clinical investigation of disease in children, usually con- 
sidered so difficult, is in some respects easier than the same study 
in adults. 

It is easier because in the child disease is commonly uncom- 
plicated, rarely has its course and symptoms modified by tissue 
lesions the result of previous affections, and never by vicious 
habits, such as the abuse of stimulants and narcotics, or by 
mental over-work and nerve-strain. The confusing element of 
mis-stated subjective symptoms is also absent, while correct diag- 
nosis is greatly aided by the facility with which physical exami- 
nation of the whole body may be practiced. 

That there are difficulties to be encountered, and very grave 
ones too, is equally certain. The absence of speech in the infant 
deprives us of the important assistance afforded by correctly 

2 17 



l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

described subjective symptoms, and renders it necessary to look 
to the mother or nurse for the history of an illness. In older 
children the case is not much better, since with them words are 
not prompted by sufficient knowledge or judgment to be of 
great service. Further, the wilfulness, dislikes, fear and agita- 
tion of the child are impediments which must be overcome before 
a satisfactory examination can be made, and which will often tax 
the skill and patience of the physician to the utmost in the 
overcoming. Another source of difficulty lies in the activity of 
growth and development in infants, which renders them liable to 
be affected by slight causes, and makes disease sudden in its 
attack, short in its course and intense in its symptoms. The 
rapid development of the nervous system especially leads to con- 
fusion. The nerves bind every portion of the frame in a sym- 
pathy so close that an affection of a single part may cause marked 
general disturbance, and local symptoms are often reflected, 
directing attention to organs very distant from those really dis- 
eased. Finally, the extreme excitability of the nervous system 
of healthy children often causes a trifling illness to assume an 
aspect of the greatest gravity, while, on the contrary, the depres- 
sion of nervous sensibility that attends chronic wasting diseases 
so obscures the symptoms that a dangerous intercurrent affection 
may appear trifling or remain altogether latent. 

The plan of conducting the clinical investigation in children 
differs materially from the method adopted in adults. It is best 
to proceed in three regular stages, as follows : ist. Questioning 
the attendants ; 2d. Inspecting the child \ 3d. Physical exami- 
nation. 

1. Questioning the Attendants. 

When the patient is under eight or ten years of age, the only 
way of obtaining a knowledge of the previous history and of 
what may occur between visits, is carefully to question the mother 
or nurse. The account must be patiently elicited and listened 
to, and credited with due reference to the narrator's intelligence. 
It is well' never entirely to discredit a statement without good 



THE INVESTIGATION OF DISEASE. 19 

reason, for many women, though weak and foolish in other 
respects, are excellent observers when their powers are guided 
by affection. Besides, being thoroughly acquainted with their 
children's habits and dispositions, they will often detect devia- 
tions from health that the physician might overlook entirely. 
This part of the examination, particularly when the acquaintance 
and good will of the child has not previously been obtained, 
should, if possible, be made before entering the sick-room. By 
taking this precaution the agitation produced by the prolonged 
presence of a stranger, and its consequent trouble and delay, 
will be avoided to a great degree. 

As there are certain points about which it is always necessary 
to be informed, the adoption of a definite order of questioning 
is advisable. 

The family history as far back as the parents should first be 
ascertained. Inquiry being chiefly directed to the detection of 
chronic maladies and transmissible diseases, as tuberculosis and 
syphilis. If any deaths have occurred, their causation should be 
investigated, and an inquiry into the occurrence, or the reverse, 
of previous still-births is often important. 

Next, an outline of the child's life from birth up to the date 
of the illness in question must be obtained. This should include 
the following items : The manner of feeding during infancy ; 
whether at the breast, or from a bottle, and if the latter, whether 
cow's milk, condensed milk or the farinacea have formed the 
basis of the diet. The date of commencement and the regularity 
of dentition. The general state of health in regard to strength or 
weakness and liability to illness. The time of occurrence and 
the nature of any prominent attack of illness, especially of the 
eruptive fevers. Whether vaccination has been performed or no. 
The hygienic surroundings; for instance the healthfullness of 
the locality of residence, the sort of house and room occu- 
pied—if large, well ventilated, light and dry or the reverse, 
and the character of the clothing and food. In older child- 
ren, if at school, the time devoted to study, and if at labor, 
the nature and the hours of work. 



20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

After this it is necessary to fix the time the attack in hand 
began. The occurrence of some striking symptom, as con- 
vulsions or violent vomiting, often establishes this point beyond 
a doubt, but when there is any uncertainty the best plan is to 
question back, day by day, until a time is reached at which the 
child was perfectly well, and to date the onset from this period. 
The most common of the general indications of commencing 
illness are disturbed sleep and irritability of temper. A perfectly 
well child sleeps quietly and continuously at night, and is never 
cross. 

Having determined, as nearly as possible, the exact time of 
onset, the next step is to learn the mode of attack and the 
symptoms and course of the disease prior to the first visit. The 
questions now must be general, never leading. They must be 
sufficiently exhaustive to touch upon all the functions of the 
body, and when a trail is started it must be patiently followed 
to the end. Alterations in sleep, bodily strength, surface tem- 
perature, appetite, digestion, urine elimination, respiration and 
so on, must be sought for, and the account of such deviations 
from the normal state as vomiting, diarrhoea or cough, will 
suggest further questions as well as point out the path to be 
followed in the future examination. 

This portion of the investigation is closed by an inquiry into 
the treatment that "may have been already adopted. 

2. Inspecting the Child. 

When the eye and ear of the physician are trained to their 
work, valuable information can be obtained by simply looking at 
an ill child and listening to its cry or spoken words. Even 
while the child is lying asleep or sitting quietly in the nurse's 
lap many facts may be learned, but this portion of the examina- 
tion is never complete without an inspection of the naked body. 
The points thus ascertained consist in alterations in the expres- 
sion of the face, in decubitus, in the appearances of the body 
and so on, and may be designated the features of disease. The 
relative position of the observer and patient during inspection is 



THE INVESTIGATION OF DISEASE. 21 

of importance. If possible the former should stand with his 
back to, and the latter be so placed that his face is toward, a 
window or lamp. The light must never be strong enough to 
dazzle when the countenance is the object of inspection, as this 
causes distortion of the features. 

For convenience, the features of disease will be studied under 
different headings, and since to appreciate them it is necessary 
to have a knowledge of the healthy aspect, both the normal and 
abnormal appearances will be described. 

Face. — The face of a healthy, sleeping child wears an ex- 
pression of perfect repose. The eyelids are completely closed, 
the lips slightly parted, and while a faint sound of regular 
breathing may be heard, there is no perceptible movement of 
the nostrils. Incomplete closure of the lids with more or less 
exposure of the whites of the eyes is noted when sleep is ren- 
dered unsound by moderate pain and during the course of all 
acute and chronic diseases, particularly when they assume a 
grave type. Twitching of the lids heralds the approach of a 
convulsion, and at such times, too, there is often oscillation ot 
the eyeballs, or squinting. A marked smile, due to contraction 
of the muscles about the mouth, signifies abdominal pain or 
colic, and pursing out of the lips and chewing motions of the 
jaw, gastro-intestinal irritation. Dilatation of the alae nasi, with 
or without noisy breathing, points to embarrassed respiration, 
the result of extensive bronchial catarrh, pneumonia or pleurisy 
with effusion. 

When awake and passive the healthy infant's face has a look 
of wondering observation of whatever is going on about it. As 
age advances the expression of intelligence increases, and every 
one is familiar with the bright, round, happy face of perfect 
childhood, so indicative of careless contentment, and so mobile 
in response to emotions. 

The picture is altered by the onset of any illness, the change 
being in proportion to the severity of the attack. An expression 
of anxiety or of suffering appears, or the features become pinched 
and lines are seen about the eyes and mouth. Pain most of all 



22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

sets its mark upon the countenance, and by noting the feature 
affected it is often possible to fix the seat of serious disease. 
Thus, contraction of the brows denotes pain in the head ; sharp- 
ness of the nostrils, pain in the chest ; and a drawing of the 
upper lip, pain in the abdomen. As a rule, the upper third ot 
the face is modified in expression in affections of the brain, the 
middle third in diseases of the chest, and the lower third in 
lesions of the abdominal viscera. 

M. Jadelot has drawn attention to certain furrows that appear 
on the face in serious cases, and to the indications that these 
affond as to the part of the body to be further examined. There 
are three sets of furrows. First, the oculo-zygomalic, beginning 
at the inner canthus of the eye and passing outward beneath the 
lower lid, to be lost a little below the most prominent portion of 
the cheek. This points to primary or secondary disorder of the 
cerebro- nervous system. Second, the nasal, starts above the ala 
of the nose, and, passing downward, forms a semicircle around 
the angle of the mouth. This may be associated with another 
line, the ge?ial, which extends from its middle almost to the 
malar bone. These indicate disease of the gastro-intestinal 
tract, or other abdominal viscera. Third, the labial, com- 
mencing at the angle of the mouth and running outward, to be 
lost in the lower part of the face. This furrow is more shallow 
than the others. It directs attention to the lungs. These furrows 
are often present, and when met with are worthy of considera- 
tion, but their constancy and value have been over-estimated 
by their discoverer. 

Pufflness of the eyelids and a fulness of the bridge of the nose, 
indicate dropsy and should direct attention to the kidneys as the 
seat of disease. Each of the two prominent diatheses is distin- 
guished by a peculiar physiognomy. When there is a tuberculous 
tendency the face is oval and the features delicate ; the hair is 
fine and silky ; the skin smooth and transparent ; the temporal 
veins are visible ; the eyelashes are long and curving, the irides 
large and deep-colored and the sclerotics pearly white or bluish ; 
finally, a growth of fine hair is often noticeable on the temples 



THE INVESTIGATION OF DISEASE. 23 

and in front of the ears. The general expression is most intelli- 
gent. In the strumous diathesis, on the contrary, the face is 
round and heavy ; the complexion doughy ; the upper lip swollen ; 
the nostrils wide and the alae of the nose thick ; the eyelids are 
thickened and reddened at their edges ; the hair coarse, and the 
lymphatic glands of the neck enlarged. 

A marked disfigurement of the face may indicate one of several 
diseases, according to its character. For example, broadness of 
the bridge of the nose, or complete flatness at this point, is sig- 
nificant of constitutional syphilis. A large, square head and pro- 
jecting forehead with a face of natural size or smaller, shows that 
the child has suffered from rickets. An immense globular head, 
overhanging forehead, and diminutive face with eyeballs pro- 
jected downward and irides almost concealed by the lower lids, 
are pathognomonic signs of chronic hydrocephalus. 

Decubitus. — The complete repose depicted on the countenance 
of a sleeping child when free from illness is shown also by the 
posture of the body. The head lies easy on the pillow, the 
trunk rests on the side slightly inclined backward, the limbs 
assume various but always most graceful attitudes, and no move- 
ment is observable but the gentle rise and fall of the abdomen 
in respiration. In the waking state the child, after early infancy, 
is rarely still. The movements of the arms, at first awkward, 
soon become full of purpose as he reaches to handle and examine 
various objects about him. The legs are idle longer, though 
these, too, soon begin to be moved about with method, feeling 
the ground, in preparation, as it were, for creeping and walking. 

With the onset of disease the scene changes. In acute attacks 
attended with pain, sleep is no longer restful. The infant is con- 
tent only when rocked, fondled or "walked" in the nurse's 
arms. The older child tosses about uneasily in bed, or demands 
a constant change from the bed to the lap. During the waking 
hours the movements are purposeless, quick and impatient, the 
position is constantly shifted and frequent whining complaints 
are made. As a contrast to this condition of jactitation, at the 



24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

beginning of the specific fevers, children often lie for hours quiet 
and drowsy upon the bed or lap. 

In chronic affections attended with debility, the movements 
become slow and languid, and in stupor and coma there is perfect 
stillness and immobility. 

There are certain positions and gestures which have especial 
significance. 

Sleeping with the head thrown back, and the mouth open, is a 
frequent accompaniment of chronic enlargement of the tonsils. 
A tendency to " sleep high," that is with the head and shoulders 
elevated by the pillow, indicates impaired pulmonary or cardiac 
function. So, too, does an upright position in the nurse's arms, 
with the chest against her breast and the head hanging over her 
shoulder— a posture assumed by young children. "Sleeping 
cool," namely, resting only after all the bed-clothing has been 
kicked off, is an early symptom of rickets. 

The position termed " en chien de fusil" is a symptom of the 
advanced stages of cerebral disease, especially tubercular menin- 
gitis. The child lies upon one side, with the head stretched far 
back, the arms pressed close to the sides and folded across the 
chest, the thighs drawn up toward the abdomen, the legs flexed 
on the thighs and the feet crossed. Restless movements of the 
head or boring of the head into the pillow also point to cerebral 
disease. 

When there is an evident desire to retain one position, as on 
the back or one side, together with short, quick breathing, some 
inflammatory change in the respiratory or abdominal organs may 
be suspected. Persistent lying on the face is an evidence of 
photophobia. 

Of the gestures, the frequent carrying of the hand to the head, 
ear or mouth indicates headache, earache or the pain of denti- 
tion respectively, and constant rubbing of the nose is a feature 
of gastro-intestinal irritation. 

If the thumbs be drawn into the palms of the hands, and the 
fingers tightly clasped over them, or if the toes be strongly flexed 



THE INVESTIGATION OF DISEASE. 25 

or extended, a convulsion may be expected. The presence of 
clonic contractions of the muscles, with unconsciousness, indi- 
cates, of course, a convulsion ; while irregular, badly coordinated, 
jerky movements — consciousness being retained — attend chorea. 

In infants the existence of colic is shown by repeated extension 
and retraction of the legs, clenching of the hands into fists, 
flexion and extension of the forearms, and a writhing movement 
of the trunk. 

The fact of one limb remaining passive while the others are 
actively moved about, naturally suggests motor paralysis. 

The Skin. — In the new-born infant the color of the skin varies 
from a deep to a light shade of red. After the lapse of a week 
this redness fades away, leaving the surface yellowish-white. 
Sometimes the yellow hue is so deep that it might readily be 
mistaken for jaundice were it not for the whiteness of the con- 
junctivae, and the absence of disordered digestion and other 
symptoms of ill-health. Usually in a fortnight all discoloration 
disappears, and the skin assumes its typical appearance. Allow- 
ing for the natural variations in complexion, the skin of a healthy 
child is beautifully white, transparent and velvety. The cheeks, 
palms of the hands and soles of the feet have a delicate pink 
color, and the general surface is rosy in a warm atmosphere, 
marbled with faint blue spots or lines, in a cool one. As age 
advances, the coloring becomes more pronounced, and until the 
completion of childhood the complexion is much fresher than in 
adult life. 

In the inspection alterations of the skin of the face are chiefly 
noticeable. Lividity of the eyelids and lips is a sign of imper- 
fect aeration of the blood, and points to pulmonary or cardiac 
disease. Marked blueness of the whole face is a symptom of 
morbus cczruleus, and indicates a congenital malformation of the 
heart. On the other hand, a faint purple tint of the eyelids and 
around the mouth shows weak circulation merely, or, more fre- 
quently, deranged digestion. 

A decided yellow hue of the skin and conjunctivae is seen in 
jaundice ; an earthy tinge of the face in chronic intestinal dis- 



26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

eases; a waxy pallor in renal diseases, and paleness in any acute 
or chronic affection attended with exhaustion. 

Brownish-yellow discoloration of the forehead is significant ot 
inherited syphilis; a bright, circumscribed flush on one or both 
cheeks, of inflammation of the lungs or pleura, or of gastrointes- 
tinal catarrh, according to its occurrence with or without an 
elevated surface temperature. 

The cutaneous lesions of certain of the eruptive fevers appear 
first upon the face ; each of these has its special characteristics. 
An eruption of herpetic vesicles on the lips may be mentioned as 
present both in pneumonia and in malarial fevers. 

Some information may be obtained from the hands. Slight 
want of proper aeration of the blood is shown by blueness of the 
finger nails, a greater degree, by cyanosis of the whole hand. 
Deformity of the nails is a symptom of syphilis : clubbing of the 
finger tips of chronic lung disease; and redness, swelling and 
suppuration about the nails of struma. The dropsy of scarlatinal 
nephritis causes a puffiness and cushiony appearance of the dor- 
sum of the hands. Often, too, in this condition, the finger 
ends are glossy, as if smeared with oil, and there is an exfolia- 
tion of the epidermis about the nails. The last two symptoms 
frequently serve to confirm a retrospective diagnosis of scarlet 
fever. 

Mode of Drinking. — By watching a child taking the breast 
or bottle, some knowledge can be obtained of the condition 
both of the mouth and throat, and of the respiratory organs. 

If there be any soreness of the mouth the nipple is held only 
for a moment, and then dropped with a cry of pain. When the 
throat is affected deglutition is performed in a gulping manner, 
an expression of pain passes over the face, and no more efforts 
are made than required to satisfy the first pangs of hunger. 
Under similar circumstances older children drink little and 
refuse solid food entirely. 

An infant suffering from the oppression of pneumonia or 
severe bronchitis, seizes the nipple with avidity, swallows quickly 
several times, and then pauses for breath. In older patients the 



THE INVESTIGATION OF DISEASE. 27 

act of drinking, which should be continuous, is interrupted in 
the same way. 

If the finger be put into the mouth of a healthy baby it will 
be vigorously sucked for some little time. The diminution of 
the act of suction during a severe illness is a sign of danger ; its 
reestablishment a good omen. In conditions of stupor and 
coma it is noticeably absent. 

The Cry. — The vocal sound, termed crying, is the chief it 
not the only means that the young infant possesses of indicating 
his displeasure, discomfort or suffering. Even long after the 
powers of speech have been developed, the cry continues to be 
the main channel of complaint. It may be accepted, as a rule, 
that a healthy child rarely cries. Of course, some acute pain, 
as from a fall or accident or blow, will cause crying in the most 
healthy child, but the storm is quickly over. Nothing like fre- 
quent, peevish crying or fretfulness is compatible with health, 
consequently, when this disposition exists, the cause must be 
looked for in some disease. 

Incessant, unappeasable crying is due to one of two causes, 
namely, earache or hunger, and the distinction may readily be 
made by putting the child to the breast or offering a properly 
prepared bottle. The hydr encephalic cry, denoting pain in the 
head, is a sudden, sharp and very loud shriek, occurring at 
intervals and audible at a considerable distance. Crying during 
an attack of coughing, or for a brief time afterwards, and at- 
tended with distortion of the features, indicates pneumonia. In 
acute pleuritis, the cry also accompanies the cough, but it is pro- 
duced too by movements of the body and by pressure on the 
affected side. It is louder, indicative of greater suffering, and 
sometimes most difficult to check. Intestinal pain causes crying 
just before or after an evacuation of the bowels, and is associated 
with wriggling movements of the body and pelvis, and with the 
eructation or passage of flatus. Conditions of general distress 
or malaise predispose to fits of fretful crying, the paroxysms 
being excited by any disturbing influence, or even by merely 
looking at the little sufferer. 



28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

When the cry has a nasal tone, it indicates swelling of the 
mucous membrane of th< or other obstru< til lition. 

Thickening and indistinctness oa urs with pharyngeal affections. 
A loud, brazen cry is a precursor of spasmodic croup. Hoarse- 
ness points to a lesion of the laryngeal mucous membrane, either 

catarrhal or syphilitic in nature. In membranous croup, and in 
some cases of extreme exhaustion, tin- cry IS taint and inaudible. 

Finally, in severe croupous pneumonia, in extensive pleura] 
effusion and in rickets, ordinary disturbing causes are inopera- 
tive for the l I on of fits of < rying, and there is a -reining 

unwillingness to cry, on account of the action interfering with 
the respiratory (unction. 

The conditions of altered tone apply equally to the articulate 

voice in children who aie old enough t.> spc\ik. 

The COUgh, too, roust not 1 Many of its char- 

acters correspond with the voice and cry. It is brazen in 
spasmodic croup, suppressed in true croup, hearse- in laryngeal 
catarrh, and so on. But it rtain featui its own. In 

bronchitis it is more or !c>s paroxysmal, evidently dry in the 

early stages, loose and rattling a- the catarrh 4 * breaks up." In 
the painful pulmonary affections, pneumonia and pleurisy, it 

choked hack, and whenever it occurs, an ion of pain 

pa>ses like a cloud over the IS, the peculiar 

ismodic cough is the pathognomonic symptom, and wl. 

once heard, immediately stamps the case. Con. always 

unproductive, that is, unattended by <--\: lion, in children 

under seven years of age 

The formation of tear> rarely begins before the third or fourth 
month of life. Subsequently, an alteration in this secretion may 
be of aid in forecasting the result of disease. The prognosis is 
bad when the tears become suppressed ; good when the secretion 
continues during an illness, or when it reappears after being 
suppressed. 

There are three other sources of information which can and 
should be investigated before proceeding to the physical exam- 
ination, although, strictly speaking, they do not come under the 



THE INVESTIGATION OF DISEASE. 29 

head of inspection of the child. These are the characters of 
the faecal evacuations, of the urine, and of the material ejected 
by vomiting. 

The Breath. — The breath of a healthy infant or child should 
be odorless, or as the nurse will say, "sweet," except perhaps 
immediately after taking nourishment, when it may, for a short 
time, have the smell of milk or any special food eaten. The 
persistent presence of an odor, therefore, is abnormal and in- 
dicates disease. 

Any morbid condition of the system that prevents the elimi- 
nation of metamorphosed nitrogenous tissue through the mucous 
membrane of the intestines, or retards the passage of decom- 
posing detritus along the bowels, will cause an offensive breath. 
Under this head are conditions characterized by high tempera- 
ture, catarrhal inflammations of the gastro-intestinal tract, chronic 
debilitating diseases, etc. The same result, also, frequently 
attends structural lesions of the kidneys. The reason for this 
is, that the system, in order to get rid of poisonous matter — 
for accumulated waste is poison — and to maintain the balance 
between the constant construction and destruction of tissue, 
must throw off elsewhere what the intestinal glands and the 
kidneys fail to excrete ; so the lungs take on vicarious activity 
and the expired air becomes tainted with the products of waste. 
Very often, by the way, the skin takes a part in the abnormal 
excretory process, and a similar odor is noticed in the per- 
spiration. 

Purely local causes of halitosis also exist. These are decayed 
teeth, caries of the nasal and maxillary bones, ulceration of the 
mucous membrane of the mouth, nose, larynx, trachea and 
bronchial tubes, and gangrene of the cheeks. 

Chronic poisoning by lead, arsenic and mercury, though not 
very common in childhood, is another cause of ill-smelling 
breath. 

To speak in general terms, the breath may become sour, 
catarrhal, fetid, gangrenous, ammoniacal and stercoraceous. 
This classification is a rude one, and many subdivisions can be 



3Q DM .„ DIGE8T1VI OKGAM U CHILDREN. 

made of some of the odow. Thus, .lK-rc arc man] wietia of 
catarrhal and fetid breath, which, whiten less distinctive 

different conditions, cannot be differentiated in words and m 
be experienced by the observer's * cognised; 

once this is done they become valuable symptoms. 

r breath is nt, in it *ially, when there 

Btric fermentation. The rai « *« "> ilk « 

farina, maketlittl. nee in H» 

ismost Bdedb nandvomitu 

In chronic romiting, chronk - colitis and thrush the 

intciw " U m ' 

the whole mo* I ' , 

What I btt nhalhreathl 

numen i les of i 

[nchr0 ni« he pharynx there is 

breath, not n »te tar from the patient' I < 

always more n "»d is 

ileepof night, asthenthemw which the odor i 

being rerooi ' n ''' N In ' 

Should tarrh invade the 1 » deeply, and, . By, 

should there be ted folhcular tonsillitis, the breath, 

I havii qnaUty of he 

that of, I IS 

very penetrating. This odor, too, ifter steeping. 

II the onset h tbe breath 
come, decidedly tanned. Sometimes it ha. a vii 

other, it n,a*d I 

in which it had the same i ifter an inl tber. 

1 ater in the attack it becomes wur or has the f sulphuret 

hydrogen. The former is apt to he the case with infants, the 
latter with older children, who have a more sohd albuminoid 

l " What is known as a "I breath " has a heavy swei 

smell It is met with in di~ f high temperature and 

depends partly upon catarrh of the gastro-intestinal mis 

membrane, the common attendant of fevers, and partly ujxm 



THE INVESTIGATION OF DISEASE. 31 

the elimination of fever waste. It is very marked and rapid in 
appearance in scarlatina. 

In chronic intestinal catarrh with obstinate constipation the 
breath often has a slightly fecal odor. 

Simple catarrh of the nasal mucosa when of any standing, gives 
rise to moderate heaviness, and the same is true of catarrh of 
the mucous membrane of the mouth — stomatitis — though in the 
latter affection, mastication and swallowing being difficult, small 
quantities of food collect in the mouth, and there undergoing 
decomposition add an element of fetor to the breath. 

Fetor of the breath is observed in its mildest form in such 
affections as aphthae and ulcerative stomatitis. It is better de- 
veloped in ozaenaeand necrosis of the maxillary bones, when the 
well-known stench of dying bony tissue is added. Decaying 
teeth give much the same odor, though it is less strong and pene- 
trating. In all these conditions, however, the fetor differs not 
only in degree, but in kind. 

Noma gives rise to a gangrenous odor, and a patient affected 
with this disease will fill the ward of a hospital, the room in 
which he lies, or even a whole dwelling, with the most sickening 
stench. Cases of empyema, with ulceration of the lung and 
discharge of pus through the bronchial tubes, have an almost 
equally offensive breath, but here there is often a flavor of garlic 
combined with that ordinarily due to tissue necrosis. 

Ammoniacal breath is observed only in patients suffering with 
uremic poisoning. 

A purely stercoraceous breath is rare, and when met with is 
an accompaniment of fecal tumor or of intussusception. 

The metallic poisons while giving rise to fetor of the breath 
have no individual characteristics, and it is necessary to look to 
the history and symptoms of the individual case to determine 
the special poison. 

The FiBCAL Evacuations. — The daily number of evacuations 
natural for a child varies greatly with its age. For the first six 
weeks there should be three or four stools every twenty-four hours. 



32 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

After this time up to the end of the second year, two movements 
a day is the normal average. Subsequently, the frequency ot 
defecation is the same as in adults — once per diem — though two 
or three movements in the same interval often occur, especially 
after over-feeding or after eating food difficult of digestion, and 
must be looked upon as conservative rather than as the evidence 
of ill-health. 

During the first period the stools have the consistence of thick 
soup, are yellowish-white, or orange-yellow in color, with some- 
times a tinge of green, have a faint fecal, slightly sour odor, and 
are acid in reaction. In the second, they are mushy or imper- 
{ec\\y formed^ of uniform consistence throughout, brownish-yellow 
in color, and have a more faecal odor. The last two characters 
become more marked as additions are made to the diet. After 
the completion of the first dentition the motions have the same 
appearance as in adult life, they axt forme d> and brownish in color, 
with a decided frecal odor. 

Many alterations occur in disease. The frequency of the move- 
ments may be inereased, constituting diarrhoea, or lessened, con- 
stituting constipation. In the former condition the consistency 
is diminished, in the latter increased. Instead of being uniform 
throughout, the stool may be mixed, partly liquid partly solid, 
indicating imperfect digestion, and curds of milk and pieces ot 
undigested solid food may be mingled with the mass. Flaky, 
yellowish or yellowish-green evacuations, containing whitish, 
cheesy lumps, are also met with in cases of indigestion. Scanty, 
scybalous stools, dark brown or black in color, and mixed with 
mucus, are characteristic of intestinal catarrh. Doughy, grayish, 
or clay-colored motions show a deficiency of bile. An intermix- 
ture of blood, altered blood clots, and shreds of mucous mem- 
brane, indicate some breach of continuity in the intestinal lining, 
such as occurs in follicular enteritis, typhoid fever, dysentery and 
tubercular disease. Watery, almost odorless stools occur in the 
latter stages of entero-colitis ; most offensive, carrion-like motions, 
in both catarrhal and tuberculous ulceration of the intestines, 



THE INVESTIGATION OF DISEASE. 33 

and sour-smelling evacuations in the diarrhoea of sucklings. The 
discovery of worms or their ova in the stools is the certain evi- 
dence of the existence of intestinal parasites. 

This mere outline of the changes that may take place will serve 
to show how much may be learned from the stools, and the 
importance of making a personal examination of them. 

The Urine. — It is impossible to make a definite statement as 
to the number of times the urine is voided by a healthy infant, 
in each twenty-four hours. In any given case the frequency will 
differ very much from day to day, depending upon the tempera- 
ture of the surrounding air, the amount of moisture that it con- 
tains, and so on. Sometimes it will be necessary to change the 
diaper every hour during the day and three or four times at night. 
Again it may remain dry for six, eight, or even ten hours. 
Neither condition indicates disease, and between the two ex- 
tremes there is a wide range of variation. Should the urine not 
be passed for twelve hours or more, a careful examination should 
be made to discover and remedy retention. 

As the child grows older the frequency diminishes, and at the 
age of three years the number of voidings will be reduced to six 
or eight during the waking hours, and perhaps one at night. 
When the desire does arise during sleep, the child, if in a normal 
state, wakes up and demands the chamber, and never passes urine 
unconsciously. Wetting the bed, therefore, or the involuntary 
passage of the urine during sleep, is indicative of an abnormal 
condition and requires investigation. 

Painful micturition points to inflammation of the urethra, a 
narrow preputial orifice, a highly acid condition of the excretion, 
or stone in the bladder. 

The urine of a healthy infant, while it wets, should not stain 
the diaper, the fluid being clear and almost colorless. It has a 
low specific gravity — 1.003 to I -°°6 — and an acid reaction pro- 
duced by the considerable amount of uric acid it contains.* As 



* The specific gravity falls markedly during the first few days after birth, on 
account of the ingestion of food. Alantoin is present in abundance during the 



34 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

childhood advances, the adult characters are more and more 
nearly approached. 

The normal daily amount excreted cannot be stated absolutely, 
since it is difficult to collect the urine in infants and very young 
children, and since, in children of all ages, the flow depends so 
much upon circumstances quite compatible with average health. 
Thus it is influenced by the state of the weather, the condition 
of the various emunctories, the amount of blood pressure in the 
renal vessels, the state of the nervous system, and the quantity ot 
solids and liquids consumed. However, from a few observa- 
tions, I am led to believe that the quantity of urine voided by 
healthy children from the fourth to the seventh years is not nearly 
so large as supposed ; eighteen to twenty ounces being the average 
in several cases in which I have lately made measurements. 

Increased secretion of urine is a prominent symptom in dia- 
betes insipidus and mellitus, and as a transient event is encoun- 
tered after an attack of abdominal pain, an epileptic fit, a par- 
oxysm of ague and a convulsive seizure. Diminution may result 
from diarrhoea and vomiting, from extreme prostration due to 
deficient nutrition or other causes, and from renal congestion, 
whether occurring in Bright' s disease or in diseases of the heart 
and liver. In febrile conditions the flow is diminished, while 
the proportion of solids excreted is normal or increased ; the 
specific gravity, in consequence, is high. Complete suppression 
may occur when general prostration and renal congestion become 
intense. 

The quantity of solids excreted in health is also subject to 
great variation. The amount of urea passed by a child is rela- 
tively greater (1.7) than in the adult. Between the ages of three 
and six years, according to Uhle, one gramme of urea for every 
kilogramme of weight is voided every twenty-four hours. Eustace 
Smith, from a rough calculation based on the specific gravity of 
the urine, estimates that the solids excreted daily between the 

first weeks of life. Pyrocatechin (Ebstein and Miiller) is also present, but 
indican (Senator) is not found in the urine of the newborn. 



THE INVESTIGATION OF DISEASE. 35 

ages of four and ten years, amount to five grains to each pound 
of weight. 

The normal acidity of the urine is increased by trifling agencies. 
A urine so affected deposits urates on cooling, or may indeed be 
turbid when passed and while still warm. Often the urates are 
so abundant as to render the fluid thick and milky-looking. In 
addition to increased acidity, this excess may depend upon an 
augmented secretion of salts. Over-feeding is the cause of the 
latter, and this relation of cause and effect must be borne in mind 
in the treatment of convalescence from acute diseases, during 
which a turbid urine is often seen. Free uric acid in the form of 
fine red sand is sometimes observed. Specific gravity and color 
vary with quantity. 

Two abnormal ingredients — albumen and blood — are fre- 
quently present in the urine of children. 

Albumen, though a frequent attendant of organic kidney dis- 
ease, by no means always indicates the existence of such a con- 
dition. It attends many febrile and inflammatory affections; is 
always to be detected where blood or pus are present, and 
appears where there is passive congestion of the kidney from 
chronic disease of the heart, liver or lungs. 

Again, transient albuminuria may arise from very slight causes. 
School children often have it during an examination or through- 
out the time given to preparing for it. Dr. Kinnicutt ascribes 
this to passing oxaluria or lithuria. It is also seen in children 
living in ague districts. Sometimes over-fatigue or the mere 
ingestion of a hearty meal will produce it, and some patients 
have it habitually after eating. 

Intermittent albuminuria — albumen being present one day 
and absent the next — is generally due to an admixture of secre- 
tions, and often indicates the habit of masturbation. 

The source of blood in the urine may be the ureters, the blad- 
der or the urethra, as well as the kidneys. In the first three 
cases the blood and urine are passed separately, while in renal 
hemorrhage the two liquids are intimately blended. When 
large quantities of blood are voided the cause of bleeding is, as 



36 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

a rule, either purpura hemorrhagica or a renal calculus. Scarla- 
tina frequently, and the other exanthemata occasionally, produce 
bloody urine, through intense renal congestion, and the same 
result is sometimes brought about by the severe diarrhoea of 
entero-colitis or cholera infantum, the appearance of blood fol- 
lowing suppression of the urine. 

Many special diseases are attended by alterations in the urine. 
Affections of the kidneys stand, of course, at the head of the 
list. 

Acute Bright's disease and scarlatinal nephritis have a urine 
diminished in quantity ; of high specific gravity ; a smoky, black- 
ish hue, as if there had been an admixture of soot; with albu- 
men, blood and epithelial, granular and hyaline tube-casts as 
abnormal constituents. In chronic Bright* S disease the quantity 
varies, being either about normal or excessive; the specific 
gravity is low and the amount of solids diminished; the reac- 
tion is acid ; uric acid crystals may appear; hyaline and granu- 
lar casts are quite constant, but albumen is often absent. Sud- 
den exacerbations produce the characteristics of the acute form 
of the disease. 

Passive congestion of the kidneys causes albuminuria with 
epithelial and blood casts; renal calculus and lithaemia — great 
acidity, with the deposit of uric acid sand, and sometimes blood 
and albumen, and sarcoma of the kidney — albumen and blood 
at times. 

Simple catarrh of the bladder is attended by an albuminous 
urine, which is sometimes very offensive and may contain pus, 
vesical epithelium and phosphates ; the reaction is usually 
alkaline. Tubercular cystitis gives rise to a cloudy, thick urine, 
containing a trace of albumen, blood or pus. 

In incontinence the secretion is, in some cases, highly acid 
and, on standing, deposits crystals of uric acid. 

In hydronephrosis the specific gravity is low, the fluid may be 
either clear or turbid, and is faintly alkaline. The urine salts 
are reduced in quantity, and crystals of oxalate of lime are often 
detected by the microscope. 



THE INVESTIGATION OF DISEASE. 37 

In malarial fever there is usually a profuse discharge of limpid 
fluid at the conclusion of the hot stage. During it, according to 
Gee, the urea and chloride of sodium are increased, the phos- 
phates diminished ; after the temperature falls, however, the phos- 
phates are increased and the urea and chloride of sodium are 
diminished. Patients living in highly malarious districts often 
show albumen and blood or its coloring matter in their urine. 

Throughout the first stage of typhoid fever the urine is scanty, 
has a high specific gravity and contains an excess of urea and 
uric acid, but few chlorides. Later it is freer, with diminished 
density, and may, if the temperature be high, contain albumen. 

Fevers as a class produce scanty, dense, high-colored urine, 
cloudy with lithates, and albuminous when an elevated tempera- 
ture is maintained. 

Croupous pneumonia gives well-marked changes, the quantity 
is diminished, the specific gravity high, the urea and uric acid 
above the average, the chlorides diminished or entirely absent 
at the extremity of the disease, and albumen often present. 
After the crisis the chlorides reappear. 

In diphtheria the urine is usually clear but may be smoky, urea 
is increased, and albumen and hyaline and granular casts may be 
discovered ; in membranous croup, on the other hand, it is 
generally normal. 

A scanty, high-colored urine, and one which deposits a whitish 
or pinkish sediment (lithates) on standing, is symptomatic of 
acute digestive disorder. Uric acid sand is sometimes seen in 
acute gastric catarrh, an excess of indican in inflammatory diar- 
rhoea when the small intestines are chiefly involved, and albumen 
in severe cases of thrush. Suppression attends grave entero- 
colitis and cholera infantum, while acute peritonitis and, occa- 
sionally, dysentery and the irritation of seat worms induce 
retention. 

In icterus neonatorum the urine is yellow in color, but con- 
tains no biliary coloring matter. Panot and Robin detected 
yellow, amorphous masses having different chemical reactions 



38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

from bile pigment, with uric acid; urates; oxalate of lime; 
hyaline, epithelial and fatty casts and white blood corpuscles. 
In catarrhal jaundice it is dark yellow, or even brownish, and 
contains bile coloring matter. Cirrhosis of the liver, in the 
hypertrophic stage, shows a yellow urine; in the atrophic, a 
fluid highly acid and filled with lithates and uric acid crystals. 
Amyloid degeneration is often associated with a similar disease 
of the kidneys, and the urine is altered in consequence, being 
copious, pale, lemon-yellow in color, of low specific gravity and 
containing albumen and hyaline tube casts ; the latter do not 
present the ordinary color reactions of amyloid material with 
iodine. Ascites has a scanty, high-colored and sometimes albu- 
minous urine. 

Acute articular rheumatism presents a febrile urine, and in 
rheumatism of the abdominal muscles the urine is reduced in 
quantity, high colored and very acid. 

Vomiting. — Both vomiting and regurgitation are of ready pro- 
duction and frequent occurrence in infancy, on account of the 
vertical position and cylindrical outline of the stomach at this 
period of life. 

Babies suckled at an abundant breast, and who are in the 
best possible state of health, often vomit habitually. In these 
cases, the supply of food being large, the infant as it lies at the 
breast is apt to draw more than it needs and more than it can 
digest. The stomach rids itself of this over-supply by an act 
which more nearly resembles regurgitation than vomiting, and 
which must be regarded as an evidence of health rather than the 
reverse. There is no violent effort or retching, the material 
ejected is the breast milk alone, either entirely unaltered or 
slightly curdled, and there are no symptoms of nausea, such as 
paleness, languor and faintness. 

In older children, vomiting may also occur after the stomach 
has been overladen. If the act be followed by relief from a feel- 
ing of general distress, headache and epigastric pain, it must not 
be regarded as a symptom of disease. 



THE INVESTIGATION OF DISEASE. 39 

Vomiting attended with the train of symptoms embraced 
under the term nausea, is not a pathognomonic symptom. It 
may indicate disease of the stomach, of the intestines, of the 
lungs and pleura, and of the brain, or it may be a prodrome of 
one of the eruptive fevers. Which condition is present can only 
be determined by watching the case, and by a careful study ot 
the rational symptoms and physical signs. 

The character of the ejecta is more definite. For instance, 
the expulsion of mucus is a symptom of gastric catarrh. The 
regurgitation of mouthfuls of curdled milk, partially digested 
food and liquid so sour that it causes a grimace to pass over the 
face, is an indication of dyspepsia with fermentation and the 
formation of acid. The appearance of lumbricoid worms in the 
vomit, a not infrequent occurrence, of course shows conclu- 
sively the existence of these parasites in the alimentary canal. 

3. Physical Examination. 

The methods of physical exploration in children are identical 
with those employed in adults, and the results do not differ in 
kind. Since, however, the object of exploration is to elicit the 
greatest amount of information with the least possible disturb- 
ance of the child, and as this very disturbance alters the character 
of some of the information obtained, it is well to adopt a some- 
what different order of examination, and one which at first sight 
may seem irregular. Thus it is best first, to ascertain the 
character of the respiration and the pulse, then to strip the body 
to determine the degree of muscular development and the condi- 
tion of the skin, next, to investigate the physical condition of the 
lungs, heart and abdominal organs, and last of all to examine 
the mouth and throat. In this order, then, the normal, as well 
as the more prominent abnormal features connected with the 
different organs will be considered. 

The Respiration. — In children the respiration is chiefly ab- 
dominal in type, irrespective of sex, and it is not until just before 
the age of puberty that the movements in the female change, 
becoming superior costal. Consequently, in estimating the 



40 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

number of movements per minute, it is best to place the fingers 
lightly on the epigastrium. The count should always be made 
by the watch, and the most convenient time for the observation 
is while the child sleeps. 

Soon after birth the number of movements per minute is 44, 
between the ages of two months and two years, 35, and between 
two and twelve years, 23. During sleep the frequency is reduced 
about twenty per cent. 

Children under two years, while awake, breathe unevenly and 
irregularly ; there are frequent pauses followed by hurry and 
precipitation, and some of the movements are shallow, others 
deep. In sleep there is greater regularity. After the second year 
the movements become steady and even, like those of adults. 
All children, however, but particularly the very young, are 
subject to a great increase in the rapidity of respiration under 
the excitement of muscular movement and mental emotion. 

Accelerated breathing occurs during the course of diseases 
attended by severe febrile symptoms, such as the acute exanthe- 
mata, the inflammatory and other affections of the thoracic 
viscera, and in rickets. Acute pulmonary lesions are especially 
characterized by this alteration, and the more the breathing 
area is lessened the greater is the increase. Thus, in pneumonia, 
60, 80 or 100 movements a minute are not at all unusual. To 
speak broadly, rapid breathing may be caused by an elevation in 
the body temperature, by an interference with the blood aeration 
and by thoracic or abdominal pain. 

As the increase in frequency may be unattended by any 
apparent effort, or true dyspnoea, it is well to make a rule of 
counting the respirations in every case in which the diagnosis is 
at all doubtful. 

Diminished frequency, the movements being reduced to 16, 
12, or even 8 in the minute, is noted in certain brain affections, 
as in chronic hydrocephalus, and in the later stages of tubercular 
meningitis. In such cases the rhythm may be greatly altered — 
a tidal form being assumed, in which the breathing ebbs and 
flows, beginning with an act which is scarcely perceptible or 



THE INVESTIGATION OF DISEASE. 41 

audible, gradually growing deeper until a full, noisy respiration 
is made, and then slowly subsiding into a period of absolute 
quiet, variable in its duration. This is termed Cheyne-Stokes' 
respiration. 

Another form of breathing, in which the alteration is mainly 
in the rhythm, is termed expiratory respiration. In the normal 
act, inspiration is immediately succeeded by expiration, and 
between the latter and the next inspiration there is a period of 
silence or rest. Expiratory respiration, on the contrary, is char- 
acterized by the pause coming between inspiration and expira- 
tion, the expiratory effort, always very marked, being immedi- 
ately succeeded by the inspiratory. This alteration occurs most 
frequently in young children, and is an evidence of dangerous 
pulmonary embarrassment. 

Perfectly healthy children breathe through the nose, and so 
softly that it is necessary to place the ear close to the face to 
hear the breezy sound of the ingoing and outgoing air. A dry, 
hissing sound, or a moist sound of snuffling indicates partial 
obstruction of the nasal passages; oral respiration, complete 
occlusion. Difficult breathing with prolonged inspiration — in- 
spiratory dysp7ioea — shows an impediment to the entrance of air 
into the lungs and indicates laryngeal obstruction, due, most 
commonly, to spasm or to the formation of false membrane. In 
such cases the inspiratory act is also attended by a loud, piping, 
or rasping sound. Labored breathing with prolonged wheezing 
respiration — expiratory dyspnoea* — occurs when the escape of air 
is impeded. The causative lesion is to be found, not in the 
larynx, but in the lungs. It may be a bronchial catarrh with 
excessive secretion, an emphysematous condition of the air 
vesicles, or asthma. In both forms of dyspncea the movements 
are slow as well as difficult, and a combination of the two forms 
is met with in cases of marked laryngeal stenosis. 

Yawning, one of the modifications of the respiratory act, if it 

* I prefer to limit the term dyspnoea to difficult or labored respiration, and 
not to extend it so as to include simple accelerated breathing. 

4 



42 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

recur frequently, denotes great failure of the vital powers and is 
an unfavorable prognostic element. 

The Pulse. — To obtain any reliable data from the pulse it 
must be felt while the patient is perfectly quiet. The best time 
is during sleep, but if the child cannot be caught in this condi- 
tion, advantage may be taken of its placidity while nursing at 
the breast, feeding from a bottle, or amused by a toy or book. 
With very young infants it is sometimes impossible to feel the 
beat of the radial artery, and it is necessary to ascertain the fre- 
quency of the pulse by directly ausculting the heart. After the 
second month palpation of the pulse at the wrist in the ordinary 
way presents no difficulties. 

The child's pulse differs from ihe adult's by being much more 
frequent, more irregular, and more irritable, and necessarily of 
smaller volume. 

The frequency, or the number of beats per minute, varies with 
the age. The following is the average rate : — 

From birth, to the 2d month, 160 to 130. 

From the 2d to the 6th month, 130 to 120. 

" " 6th " 1 2th " ... 120 to no. 

m a Ist a 3d year, no to 100. 

" "3d " 5th " 100 to 90. 

u u ^h « Iot b u 90 to 80. 

" " 10th " 1 2th " 80 to 70. 

These figures represent the pulse in a waking but passive state. 
During sleep the frequency is less. Thus between the second 
and ninth years there are about sixteen beats less per minute 
while asleep than when awake; between the ninth and twelfth 
years, eight less ; and between the twelfth and fifteenth years 
only two less. Below the age of two years the disparity is even 
greater. 

The irregularity of the pulse in childhood is confined to an 
alteration of the rhythm. It is most marked in infants and is 
greatest during sleep, when the pulse is slowest. 

The feature of irritability, that' is, the facility with which its 
frequency is increased by muscular activity and mental excite- 



THE INVESTIGATION OF DISEASE. 43 

ment, is greater in proportion to the youth of the child. A 
rise of 20, 30 or even 40 beats a minute is not uncommon in 
early infancy under the excitement of the slightest effort or dis- 
turbance. 

On account of these wide variations in health, little sympto- 
matic meaning need be attached to alterations of the rhythm and 
frequency while unassociated with other abnormal features. 
When so associated they become important in diagnosis. 

Increased frequency is a constant attendant of the febrile 
state. The extent of the increase corresponds with the degree 
of elevation of the temperature, though the pulse curve always 
runs higher than the temperature curve. The more frequent the 
pulse the higher the fever, is the rule, but in estimating the 
prognostic value of the increase, the law of the fever in ques- 
tion must be taken into consideration. For example, in scarla- 
tina a pulse of 160 is usual and not indicative of special gravity, 
whereas in measles the same degree of acceleration would be 
abnormal and show great danger. 

Jaundice and parenchymatous nephritis are accompanied by 
a diminution in the rate. 

Irregularity is met with in diseases of the brain and heart, and 
sometimes in nervous and anaemic children. 

The Temperature must be estimated before removing the 
clothing. No reliable result can be obtained without the use of 
an accurate clinical thermometer. The instrument is usually 
placed in the rectum* of the infant and young child; in the 
axilla of one old enough to understand the importance of keep- 
ing the arm in a proper attitude. It should remain in position 
at least five minutes. 

During the first week of life the temperature fluctuates con- 
siderably. After that the puerile norm — 98. 5 to 99 F. — is 
established, but until the fourth or fifth month it is greatly 
influenced by healthy causes of variation ; the fluctuations rang- 
ing between .9° and 3. 6°. By the fifth month regular morning 

* The rectal temperature is normally at least i° higher than the axillary. 



44 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and evening oscillations begin to be noticeable, and certain 
definite laws are followed. There is a foil in the evening of i° 
or 2 . The greatest fall occurs between 7 and 9 p.m. and the 
minimum is reached at, or before, 2 a.m. After 2 a.m. there is 
a gradual rise, the maximum being reached between 8 and 10 
a.m. Throughout the day the oscillation is trifling. These 
variations are independent of eating and sleeping. 

In disease there may be either a rise above, or a fall below, 
the normal standard. 

Fever is always associated with an elevation of the temperature. 
Rapid and transient rises attend slight catarrhs and passing 
indigestions; prolonged rises, inflammatory and essential fevers. 
The degree of elevation marks the type of the pyrexia. This is 
moderate when the mercury stands at 102 , severe at 104 or 
105 , and very grave above 107 . The duration of the eleva- 
tion and the peculiar range of the oscillations — for there are 
oscillations in disease as well as in health — determine the nature 
of the fever. The febrile oscillations differ from the healthy in 
that the lowest marking is noticed in the morning, the highest 
in the evening. Variations in the typical range of any given 
fever are important prognostic omens — a sudden fall of the tem- 
perature, together with improvement in the general symptoms, 
indicates the beginning of convalescence — a similar fall, with 
an increase of the general symptoms, is a precursor of death. 
When the morning temperatuie is equal to that of the preceding 
evening, there is great danger ; if higher, greater danger still. 
Marked remission in continued fevers is generally a forerunner 
of convalescence. 

Abnormal depression of temperature is occasioned by hemor- 
rhage and by the loss of fluids in cholera infantum or entero- 
colitis. It is also met with in anaemia, in atrophy from insufficient 
nourishment, in diseases of the heart and lungs attended by im- 
perfect blood aeration, and it constantly attends collapse and the 
death agony. A maintained temperature of 97 is dangerous in 
children, and for every degree of reduction below this point, the 
risk to life is more than proportionately increased. 



THE INVESTIGATION OF DISEASE. 45 

While the physician must use the thermometer, to insure 
accuracy, he can, by placing the hand on the skin, detect gross 
differences of temperature. Reductions are best appreciated by 
touching the nose and extremities, while increased heat is most 
readily felt at the back of the head and in the palms of the hands. 

Having determined the character of the respiration, pulse and 
temperature, the next step in the physical examination is to strip 
the child, in order to ascertain his general development, the 
condition of his skin, and so on. 

The General Development. — The healthy child under two 
years of age is plump of body and round of limb with well- 
developed fat cushions and firm flesh, and with the head and 
abdomen large in proportion to the rest of the frame. As age 
advances, the figure gradually assumes the characteristics of 
adolescence. 

To be robust, the newly-born child must have a certain aver- 
age size and weight. Subsequently, under normal circumstances, 
there is a regular rate of increase in both of these respects. At 
birth the length is about 16 inches. Growth is quickest in the 
first week of life. In the first year there is an increase of from 5 
to 6y^ inches; in the second, from 2^3 to 3^ inches; in the 
third, from 2^ to 23/3 inches; in the fourth, about 2 inches; 
and from the fifth to the sixteenth years the annual growth 
amounts to from ifz to 2 inches. The average weight at birth 
is from 6 to 8 pounds. The daily increase in weight should range 
from y^ to y^ of an ounce. 

With these data it is quite possible to estimate what should be 
the normal size and weight of a child at any age. Consequently, 
if, on being measured and weighed, he be found to fall short of 
the normal standard, it is proper to infer the existence of some 
fault in the nutritive processes. A conclusion still further borne 
out by a want of rotundity of outline and by flabbiness of the 
muscles. 

The age at which the child sits erect, at which it walks, and at 
which the anterior fontanelle becomes ossified, are points closely 
connected with the subject of development and nutrition. 



46 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

For some time after birth, the child, if noticed while sitting 
upon the lap, will be observed to hold the head and shoulders 
forward or to " stoop' ' a little; the spine, from the cervical 
region to the sacrum, forming a continuous curve with the con- 
vexity directed backward. Toward the end of the eighth month 
the position begins to become more erect, and in a few weeks is 
perfectly so, the spine assuming an almost perpendicular line. 
Any marked delay in this change indicates general debility. 

At the end of the fourteenth month the child should be able to 
walk alone. The spine then assumes the S like curve seen in 
healthy adults. A delay in walking may be due to systemic 
weakness or to infantile paralysis affecting one or both legs. If 
the walking be done on the toes chiefly, if the gait be limping, 
and especially if knee-pain be complained of, and manipulation 
of the limbs causes suffering, the chances are that hip-joint dis- 
ease is commencing. 

The anterior fontanelle should be ossified or completely closed 
at some period between the fifteenth and twentieth months. The 
closure is much retarded in rickets, which is preeminently a 
disease of mal-nutrition. Hydrocephalus has a like effect. In 
a state of health, the opening, while still membranous, is level 
with the cranial bones or very slightly depressed. Conditions of 
systemic exhaustion cause marked sinking, and this depression is 
one of the best indications of the necessity of stimulation. Bulg- 
ing of the fontanelle is a symptom of chronic hydrocephalus. 

Conditions of the Skin. — The normal color of the integu- 
ment, and the alterations produced by disease, have already been 
studied. The other characters possessed by the skin of a healthy 
child are, a velvety smoothness and softness, a scarcely perceptible 
moisture, and a great degree of elasticity. 

Disease causes modifications in texture, in moisture, and in 
elasticity, and leads to the appearance of various eruptions and 
to oedema. 

Mucous disease is attended with a dry, harsh skin, which is 
muddy in color, and covered, especially on the extensor surfaces of 
the arms and legs, by a more or less thick layer of exfoliating epi- 



THE INVESTIGATION OF DISEASE. 47 

dermis. Chronic abdominal affections, particularly tuberculosis 
of the intestines and mesenteric glands, lead to harshness, acridity, 
scurfiness, and a wrinkled appearance of the skin covering the 
abdomen and thorax, with enlargement of the superficial abdom- 
inal veins. 

Protracted diarrhoea, and still more, vomiting combined with 
diarrhoea, cause absorption of the subcutaneous fat and wasting 
of the muscles. The skin becomes too large for the body, is dry, 
harsh, discolored, and so inelastic that it falls into wrinkles over 
the joints when the limbs are moved, and if pinched up retains 
the fold for a long time. The condition of general atrophy 
popularly known as " marasmus, " presents these features most 
strikingly. 

Dryness is a concomitant of the febrile state ; excessive moist- 
ure, of prostration of the vital forces and collapse. 

Eruptions appear upon the integument, in the skin diseases 
proper, in the exanthemata, in constitutional syphilis and in 
certain digestive disorders. 

OEdema of the subcutaneous connective tissue may be due to 
affections of the heart, liver or kidneys. The cardiac variety 
usually shows itself first in the feet ; the renal, in the eyelids ; 
the hepatic, in the feet and legs, secondarily to ascites. 

While examining the surface it is well to look for enlargement 
of the superficial lymphatic glands and swelling of the joints. 
The former occurs in scrofula and syphilis ; the latter in 
rheumatism. 

Examination of the Abdomen. — To examine this portion 
of the body the child, still stripped, must be placed on its back, 
upon the bed or nurse's lap. Quiet is most important, since 
struggling and crying are attended by such contraction of the 
abdominal muscles and rigidity of the walls that little can then 
be learned of the condition of the contained organs. The 
methods of investigation are those ordinarily employed in 
physical examination. Palpation or percussion should never be 
made with cold hands. 

The abdomen of a healthy child is somewhat prominent, 



48 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

uniformly soft, yielding, and painless to the touch, and to percus- 
sion gives a tympanitic sound, varying in tone according to the 
region percussed. The tympanitic note being lowest in pitch 
over the epigastric and left hypochondriac regions, the seat of 
the stomach ; highest, over the umbilical region, the position of 
the small intestine. 

In disease i?ispection reveals any disproportion in the size or 
form of the abdomen, the state of the integuments, of the super- 
ficial veins, and of the umbilicus. Palpation shows the tempera- 
ture, pliability, moisture and tension of the walls, and the 
presence or absence of tenderness, of fluctuation, and of enlarge- 
ment of the mesenteric glands, and other solid viscera. Percussion 
serves to demonstrate the nature of enlargements, whether due to 
accumulation of gas or liquid, or to solid growths. By it, also, 
the outline and size of the liver and spleen may be determined. 

Distention of the abdomen is, in the vast majority of instances, 
due to flatulence. In children reduced by chronic disease the 
bowels are usually deranged, the food is badly digested, and the 
gases set free by the decomposition of the starchy foods accumu- 
late, owing to feebleness of the intestinal walls, and give rise to 
much/ swelling and discomfort. Over such an abdomen the skin 
feels tense, the umbilicus is level or slightly prominent, there is 
no tenderness on pressure, and percussion is markedly tympanitic. 

This simple cause of enlargement must be remembered, for a 
distended abdomen in a wasting child is often falsely attributed 
to caseation of the mesenteric glands. The latter disease is 
uncommon at any age, extremely rare under three years, and, 
moreover, is by no means uniformly attended by distention. On 
the contrary, unless the glandular disease be excessive, retraction 
is the rule. When distention does exist it depends upon associ- 
ated intestinal disorder, and is merely an accidental complication. 
The only pathognomonic sign is the detection of the tumor caused 
by the enlarged glands. This is situated in the umbilical region, 
and is firm, lobulated and slightly tender to the touch. It is 
most readily detected by gently grasping the abdomen on either 
side with the hands and slowly bringing the fingers together 



THE INVESTIGATION OF DISEASE. 49 

toward the median line. Percussion over the tumor yields a dull, 
tympanitic sound. Whenever there is associated flatulence it is 
difficult or impossible to detect the tumor. 

Drum-like distention, with great tenderness, and muffled tym- 
panitic percussion note occur in general peritonitis. 

Uniform distention, again, may be due to ascites depending 
upon simple or tubercular peritonitis, kidney disease, or less com- 
monly, disease of the liver. The abdomen is barrel-shaped, pain- 
less to the touch, and there is extended fluctuation. Percussion 
is dull over the position of the fluid, but in nearly every instance 
there is an area of tympany which changes its position ; moving 
always to the upper part of the abdomen, in reference to the 
posture of the patient. This variation is most important in the 
diagnosis. 

Localized distention may be traced to gaseous accumulation, 
to enlargement of the liver and spleen, to faecal accumulation, to 
circumscribed peritonitis, and to distention of the bladder. 

Collections of gas are always tympanitic on percussion. 

The extent of liver dulness is to be estimated by percussion. 
If the organ extend below the rib margin, the edge can usually 
be felt by laying the palm of the warmed hand flat upon the 
abdomen and making gentle pressure downward with the ends of 
the fingers. 

An enlarged spleen may be felt by placing the fingers of the 
right hand on the back, directly below the twelfth rib and outside 
of the lumbar muscles; the fingers of the left, on the abdomen, 
directly opposite ; then bringing the hands toward one another. 
If the hands have been rightly applied, and nothing is felt, the 
spleen may be considered to be normal in size. The fact that 
both the liver and spleen, though still unenlarged, may be more 
readily felt than natural when pressed downward by the dia- 
phragm, must not be overlooked. 

A faecal accumulation is distinguished by the absence of ten- 
derness, by the oblong shape of the tumor, by the situation in 
the region of the transverse or descending colon, to which its 
long axis corresponds, and by its shape being capable of some 



50 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

modification by pressure. Percussion over such a mass is 
dull. 

Distention of the bladder gives rise to a bulging tumor in the 
hypogastric region, which is elastic to the touch and dull on 
percussion. 

A shrunken or scaphoid condition of the abdomen is met 
with in serious brain affections, notably tubercular meningitis, 
also in cholera infantum, follicular enteritis and dysentery. 

Tenderness to pressure indicates inflammatory lesion of the 
intestines. The presence or absence of this sign in an infant 
can be determined by forcing the attention, by bringing it before 
a strong light, for instance, and then making pressure on the 
abdomen. If crying be produced, there is tenderness, if not, 
the reverse. 

Examination of the Chest. — The stethoscope and plex- 
imeter are unnecessary in examining the lungs. In the case of 
the heart, the former may be occasionally required, to localize 
murmurs. When used, it is better to give the instrument to the 
child to handle and become familiar with, before application. 
The thoracic end must never be adjusted without being warmed. 
The quieter the patient the more complete and satisfactory will 
be the results of the exploration. Unfortunately, though, it is 
too often necessary for one to do the best possible in the midst 
of cries and struggling. However, by skilfully seizing oppor- 
tune moments, much reliable information may be gained. Aid 
is also derived from the fact that in serious lung affections, as 
croupous pneumonia, the child is quiet from choice, crying 
interfering with the respiratory act, upon which his attention is 
concentrated. 

The steps of the examination are, first, inspection ; second, 
auscultation ; third, palpation ; and fourth, percussion. The 
reason for making the order different from that practiced in 
adults, is to place the most disturbing element last. Mensura- 
tion and succussion are infrequently resorted to in children. 
If required, they are best postponed until the end of the 
examination. 



THE INVESTIGATION OF DISEASE. 51 

Inspection. — The sitting posture, the child being stripped and 
in a good light, is the best for this process. Note is to be taken 
of the shape of the chest, the character of the breathing, and 
the position of the apex beat of the heart. 

In the newborn baby, the chest is nearly circular in shape, 
the antero-posterior diameter being almost as great as the 
lateral. Later, it gradually becomes elliptical, the lateral 
diameter in time considerably exceeding the antero-posterior. 
The intercostal spaces are poorly marked, and the scapulae lie so 
close that their outline is scarcely perceptible. The circular 
shape of the chest allows of little lateral expansion, and for this 
reason the respiration is chiefly abdominal in type. Together 
with the movement of the abdominal walls, every act of inspi- 
ration is attended by a certain amount of recession of the lower 
part of the chest walls, the yielding ribs being forced inward by 
the pressure of the external air before they can be sufficiently 
supported by the expanding lung. The rise and fall of the car- 
diac apex can be seen — except when there is a great accumula- 
tion of fat — a short distance below and to the right of the left 
nipple. 

Disease may alter all of these conditions. The tuberculous 
diathesis is characterized by a small chest, and one which has 
either the alar or the flat shape. In rickets the thorax becomes 
irregularly triangular in outline. Emphysema causes a barrel- 
shaped chest, with stooping shoulders and round back. Pleuritis 
with large effusion produces bulging of the affected side, and 
sometimes prominence of the intercostal spaces. After absorp- 
tion has taken place there may be marked retraction, sinking of 
the interspaces, falling of the shoulders, and curvature of the 
spine toward the healthy side. 

Cessation of the costal respiratory movements indicates in- 
flammation of the lung or pleura, or a large pleuritic effusion. 
Cessation of the abdominal play, inflammation of the peritoneum 
or of the intestines ; excessive ascites and gaseous accumulations 
produce the same effect. 

Rachitic softening of the ribs, and those diseases of the lungs 



52 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and air passages which offer a direct obstacle to the entrance of 
air, are associated with a great increase in the normal recession 
of the lower portion of the chest on inspiration. In certain 
cases, a deep furrow appears across the chest, marking the upper 
borders of the abdominal viscera. The depth of the furrow 
indicates the degree of softening and of obstruction to the 
ingoing air. 

The position of the apex beat is altered by cardiac diseases, by 
pleuritis, and occasionally by gaseous distention of the stomach. 
When the left ventricle is enlarged, it is shifted downward and 
to the left. Transmitted epigastric pulsation shows enlarge- 
ment of the right ventricle. An extended impulse is not 
necessarily a sign of disease, since the chest-walls are so elastic 
in childhood that the normal impact of the apex is apt to affect 
a wide area. The effusion of pleurisy pushes the heart to the 
right or left, while the retraction, after absorption or evacuation, 
draws it in one or other direction. The apex is pushed upward 
and to the left in gastric flatulence. Emphysema, by pushing 
the heart away from the thoracic wall, diminishes or entirely 
hides the impulse. 

Auscultation. — With infants, the back of the chest is most 
conveniently ausculted when the child is held in the nurse's left 
arm, with his breast against hers, his chin resting upon her left 
shoulder, his left arm around her neck, and his head kept in 
position by her disengaged hand. The front, when reclining on 
the back on a pillow. The sides, when sitting upright on the 
lap, first one arm and then the other being lifted up to allow the 
observer's ear to be applied. Older children may be made to 
take the same position as adults. 

It is not sufficient to auscult the posterior aspect of the thorax 
alone, as is stated by some authors. The whole chest should be 
examined, particularly in doubtful cases. The signs of croupous 
pneumonia are most frequently discoverable at one or other 
base, posteriorly ; the friction sound of pleuritis at the junction 
of the middle and lower third of the chest, laterally ; and the 
signs of emphysema at the apices, anteriorly. Therefore, 



THE INVESTIGATION OF DISEASE. 53 

unless the exploration be thorough, important lesions may be 
overlooked. 

In healthy infants the inspiratory act in ordinary breathing is 
superficial, and the respiratory murmur, as a consequence, feeble. 
If, however, a deep inspiration be taken, a frequent occurrence 
under excitement and during crying, the murmur becomes loud, 
or assumes the character that Laennec termed puerile breath- 
ing. After the age of two years this form of respiration is 
habitual. 

Puerile breathing is characterized by its intensity, a property 
depending upon the thinness and elasticity of the chest-walls in 
childhood. There is no alteration in rhythm, the inspiratory 
element of the murmur being directly followed by the expira- 
tory, and this in turn by an interval of silence ; neither is there 
any change in the pitch or duration of the expiratory sound, 
which remains lower and shorter than that of inspiration. In 
other words, puerile respiration is simply a very intense vesicular 
respiration. The normal respiratory murmur is then feebler in 
infants, and louder in children over two years old, than in 
adults. 

The breathing is loudest over the anterior, lateral and poste- 
rior inferior regions of the thorax. Faintest over the scapulae 
and the precordial area. Sometimes the expiratory element is 
wanting. This absence occurs most frequently in young chil- 
dren, and is most noticeable over the lower posterior portions 
of the lungs. In the inter-scapular region, the ear, being 
directly over the larger bronchi, readily detects a deviation 
from the vesicular quality. Here the 'inspiratory murmur is 
loud, harsh and somewhat tubular in character. There is a 
slight pause between it and the expiratory murmur, and the 
latter is longer in duration and higher in pitch. There is, in 
fact, an approach to the bronchial type of breathing, which may 
always be heard in its purity by listening over the trachea. 

Sometimes a difference in the breathing can be detected over 
the apices anteriorly. On the left side the vesicular quality is 
purer, on the right, the intensity is greater. The difference is 



54 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

most decided in the expiratory element, which, also, may be 
slightly prolonged on the right when compared with the left 
side. These modifications are due principally to the larger size 
and more horizontal course of the right primary bronchus. 
They are perfectly compatible with a normal state of the lungs. 
Should, however, the conditions at the apices be reversed, and 
the intensity and prolongation of the expiratory sound be 
greater on the left side, the commencement of phthisis is indi- 
cated. 

If the child speaks, cries, or coughs while the ear is applied 
to the chest, a muffled rumbling sound, the normal vocal reso- 
nance, will be heard. At the same time, vibration of the walls, 
the vocal fremitus, can be felt. 

To develop the respiratory sounds it is often necessary to 
instruct the patient how to breathe, and if an infant is being 
examined, to take advantage of the deep inspirations that. pre- 
cede coughing, and occur during crying. 

The cardiac sounds are readily heard when the ear is placed 
on the praecordia. In young infants the examination is somewhat 
difficult, on account of the rapid and excitable action of the 
heart, but after the first year, the circulation becoming slower 
and more regular, there is little trouble in distinguishing the 
sounds, and even slight alterations produced in them by 
disease. The first sound is longer and graver than the second, 
and the rhythm is ordinarily quite regular. In health the 
sounds may be heard under both clavicles for a short distance 
to the right of the sternum, and sometimes over the whole ante- 
rior surface of the chest. After muscular effort or during agita- 
tion, the heart sounds may be audible over the posterior aspect 
of the chest, but they are most distinct in this position when the 
lower lobe of either lung is consolidated by pneumonic exuda- 
tion. The latter point is often of great value in distinguishing 
doubtful cases of pneumonia from pleural effusion. 

Palpation. — In practicing palpation the palmar surface of the 
well-warmed hand must be applied to the naked chest. This 
method of exploration is useful as a means of determining the 



THE INVESTIGATION OF DISEASE. 55 

number of respiratory movements, the degree of expansion of 
the thoracic walls, the position of the cardiac apex beat, the 
presence or absence of painful regions and of pleural or bron- 
chial fremitus, the existence of fluctuation in the intercostal 
spaces, and the character of vocal fremitus. For the last pur- 
pose, though, it is hardly worth while to make a separate step in 
the examination, for the vocal vibrations can be readily distin- 
guished by the ear when applied to the chest in auscultation. 

Percussion. — In percussing the different surfaces of the chest, 
the child must be placed in the same positions as for auscultation. 
When contrasting the two sides, percussion should be made in 
identical regions, and during the same period of the respiratory 
movement. Babies when constrained or when disturbed, hold 
their breath in the intervals of crying, and as they always do so 
at the end of an inspiration, this is a favorable time to seize for 
the comparative examination. The percussion strokes must be 
lighter than in the adult, but in other respects the operation in 
no wise differs. 

In health the resonance will be found to correspond closely 
with the respiratory murmur. Thus, in infants under one year, 
the respiratory murmur being feeble, percussion is rather insono- 
rous. Even at this age the case is different, when a deep breath 
is taken, and so soon as puerile respiration becomes established 
the resonance is uniformly intense. With the exception of this 
greater intensity, the sound is exactly similar to that obtainable 
in adults. It is always attended, too, by a sensation of elasti- 
city, appreciated by the finger used as the pleximeter. 

Different portions of the thorax possess, normally, different 
degrees of sonorousness. 

In front, the right side is markedly resonant from the clavicle 
down to the fifth interspace, or the upper border of the sixth rib 
in the mammary line, where the liver dulness begins. On the 
left side the resonance is equally intense, but it is encroached 
upon by the gastric tympany, which extends upward as high as 
the seventh or sixth rib, as well as by the area of cardiac dulness. 
The latter forms an irregular triangle, of which one side is repre- 



56 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

sented by a vertical line passing down the middle of the sternum, 
from the level of the fourth to the sixth rib ; the other, by an 
oblique line touching the upper extremity of the first, and 
extending outward to the left, and downward, to terminate at 
the point of the apex beat ; and the base, by a line drawn from 
the central point of the lower edge of the sternum (the inferior 
extremity of the first line), along the sixth costal cartilage, to 
the apex of the heart. Diminished resonance and elasticity are 
at once noticeable when the percussion passes from the lung to 
this area, though the prsecordial dulness is never so decidedly 
marked in children as it is in adults. 

Laterally, both supra-axillary regions are very resonant. The 
upper portions of the infra-axillary regions are a degree less reso- 
nant, and the lower portions are dull on account of the presence 
of the liver on the right and the spleen on the left side. The 
superior border of the liver dulness is found in the seventh inter- 
space or at the eighth rib ; that of the spleen, at the upper edge 
of the ninth rib. Gastric tympany may supplant the pulmon- 
ary resonance over the left infra-axillary region. 

Posteriorly, there is little resonance in the scapular region, 
particularly the supra-spinous portions. Over the interscapular 
space the sound improves, but it is less resonant than anteriorly 
or laterally. Over the infra-scapular regions the resonance is but 
little less pure than in front, until the tenth rib is reached on the 
right side and the liver dulness is again met with. On the left 
side the resonance extends to the very base, the posterior splenic 
dulness being detected with difficulty. The right base is, there- 
fore, naturally less resonant than the left, and this difference is 
especially marked during expiration, the liver rising higher at 
that time. 

Affections of the lungs produce various alterations in the percus- 
sion sound. The chief of these are the substitution of tympany, of 
dulness, and of flatness for the normal resonance, and of increased 
resistance to the finger for elasticity. Cardiac diseases cause 
changes in both the extent and the shape of the area of praecordial 
dulness. 



THE INVESTIGATION OF DISEASE. 57 

Examination of the Mouth and Fauces. — This portion 
of the examination is most apt to cause crying and struggling, 
but it must never be omitted. In infants, gentle pressure of the 
fingers upon the chin is sufficient to cause wide opening of the 
mouth. An older child will frequently open the mouth when 
requested, but if he refuse, the finger, the handle of a spoon, or 
some other smooth, flat instrument maybe inserted in the mouth, 
and downward pressure made upon the tongue, when the jaws 
will be widely separated. In some cases, when the child is old 
enough to do as bid, the fauces can be seen by directing the 
mouth to be opened wide and the tongue to be alternately pro- 
truded and retracted, or a prolonged sound of "AA" to be 
made. With the refractory, and always with infants, the tongue 
has to be held down by a spoon handle or tongue depressor. If 
there be resistance, the patient must be taken on the lap of the 
nurse, who holds his back against her breast, directs his face 
toward a bright light, and controls the movements of his hands 
and feet. 

The healthy oral mucous membrane has a deep pink color, and 
is smooth, moist and warm to the touch. The color is deeper 
on the lips and cheeks, lighter on the gums. The latter, up to 
the sixth month, as a rule, have a moderately sharp edge. Sub- 
sequently, the edge begins to broaden and soften, and the color 
of the investing mucous membrane deepens to a vivid red, and 
becomes hot, as the teeth begin to force their way through. The 
first, or milk teeth, so called from their color, are twenty in 
number, all told, ten to each jaw ; they make their appearance 
in the following order, the corresponding teeth appearing a little 
earlier in the upper jaw * : — 

The two lower central incisors, from 
" four upper " " 

" two lower lateral incisors and the 

four anterior molars, from 
" four canines, " 

" " posterior molars, " 

*« Upon this point, however, there is little uniformity. 



4 to 7 m 


onthi 


5 after 1 


Dirth. 


8 to 10 


a 


a 


a 


12 to 15 


a 


a 


a 


18 to 24 


a 


a 


(i 


20 to 30 


a 


a 


a 



58 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The order of eruption of the permanent teeth is as follows 



The two central incisors of lower jaw, from 


the 6th to 8th year. 


" " " " upper " " 


" 7th to 8th " 


" four lateral " " 


" 8th to 9th " 


" " first bicuspids, " 


" 9th to 10th " 


u " canines, " 


" loth to nth «• 


" " second bicuspids, " 


" 1 2th to 13th " 



These replace the temporary teeth ; those which are developed 
de novo appear thus : — 

The four first molars, from the 6th to 7th year. 
" " second" " " 12th to 13th " 

u " third " " " 17th to 21st « 

There are, therefore, twelve more permanent teeth, making 
thirty-two in all, sixteen in each jaw. 

The tongue should be freely movable. It is pink in color, and 
the dorsum, or upper surface, marked in the centre by a slight 
longitudinal depression, has a velvety appearance, and is soft, 
moist, and warm to the finger. The velvety nap is due to the 
numberless hair-like processes of the filiform papillae. There are 
also scattered over the surface, but most closely at the tip, a 
number of eminences, the size of a small pin's head, circular in 
outline, and deeper pink than the general surface — the fungiform 
papillae. While far back, defining the papillary layer, are the 
circumvallate papillae, numbering about twelve, and arranged in 
a V-shaped row. These have the form of an inverted cone, sur- 
rounded by an annular elevation. 

The hard palate is roughened anteriorly by transverse ridges. 
The soft palate is smooth and its mucous membrane is paler than 
that of the rest of the mouth. The fauces, on the contrary, are 
redder. In the triangular recess between the half arches of the 
palate the tonsils can always be seen. They should be about the 
size and shape of almond kernels, and they present a number of 
circular openings, the orifices of pouches, into which the follicles 
open. The uvula is short and tongue-shaped. The posterior 
wall of the pharynx should be red, smooth and moist. 



THE INVESTIGATION OF DISEASE. 59 

Disease produces a great variety of changes in the mouth, 
tongue and fauces. Fever makes the mouth hot and dry, and 
causes the tongue to be frosted or coated. Affections of the 
gastro-intestinal tract are always attended by coating of the 
tongue, and the various appearances of this coating are of impor- 
tant diagnostic and therapeutic significance. Inflammation of the 
mouth itself, reddens the mucous membrane, makes it hot and 
tender to the touch, increases its moisture, alters the surface of 
the tongue and leads to the formation of aphthae, to ulceration, 
and even to gangrene. 

The eruptions of scarlet fever, measles, varicella and varioloid 
make their appearance first on the mucous membrane of the 
palate and fauces. 

Irregular dentition indicates faulty nutrition ; delayed denti- 
tion, rickets; and certain peculiarities in the formation of the 
permanent teeth, constitutional syphilis. 

Finally, the conclusive evidences of the existence of diphtheria, 
of croup, and of the various tonsillar affections, are found in the 
fauces. 



PART II.— THE GENERAL MANAGEMENT 

OF CHILDREN. 



It is the duty of the child's physician not only to remove dis- 
ease, but also to manage convalescence and every-day life in such 
a way that the little subjects confided to his care may be led to 
complete recovery, and kept in as perfect health as possible. To 
accomplish these objects, the ability to direct intelligently the 
daily regimen is much more important than a mere knowledge of 
drugs and of the principles of therapeutics. 

The daily regimen embraces several factors ; these are feeding, 
bathing, clothing, sleep and exercise, and under such headings 
the subject will be briefly outlined, for little more is possible, in 
the present chapter. 

i. Feeding. 

Age bears so close a relation to the choice of food and the 
method of feeding, that it will greatly simplify the study of these 
questions to consider them from the standpoint of the two stages 
of a child's life, namely, infancy, or the period extending from 
birth to the age of two and a half years ; and childhood, the 
time elapsing between completion of the first dentition and 
puberty. 

An Infant may be fed in either one of three ways — ist, from 
the mother's breast ; 2d, from the breast of a wet-nurse ; and 3d, 
from a bottle, the latter being the method known as artificial or 
hand-feeding. 

1 st. Feeding front the maternal breast. There can be no doubt 
that this, being the natural, is at the same time the proper method 
of nourishing the human infant ; and fortunate is the babe that, 
in our day of advanced civilization and city-living, can draw from 

60 



THE GENERAL MANAGEMENT OF CHILDREN. 6 1 

the breast of a robust mother an abundant supply of pure, health- 
giving, tissue-building food. 

It follows, therefore, that every woman who is free from certain 
contra-indicating diseases, to be mentioned later, should nourish 
her child solely from her breast up to the age of eight months, 
and partially to the end of the first year, or, failing in either limit, 
so long as possible. 

The infant should be put to the breast as soon as the mother 
has recovered somewhat from the fatigue of labor — some four or 
eight hours after birth. Of course no milk can be drawn at this 
early date, but the babe gets a small quantity of thin, watery 
fluid, called colostrum, which affords sufficient nourishment, and 
at the same time, from its laxative properties, clears away the 
greenish or black, viscid material that collects in the infant's 
intestinal canal during intra-uterine life. This procedure, too, 
is of great advantage to the mother, for it insures proper contrac- 
tion of the womb, draws out the nipples, and encourages the 
formation of milk. 

As the secretion of milk is never fully established until the 
third day after labor, it stands to reason that no food other than 
the colostrum is required before that time. Hence, the practice 
of filling the infant's stomach with gruel, sugar and water, and 
other sweetened mixtures, is more than useless, for it diminishes 
the activity of sucking and the consequent stimulation of milk 
production. Put the child to the breast every two hours while 
the mother is awake, and there need be no fear of starvation. 

After the third day, should the breasts not yield a supply of 
milk, a little pure cow's milk diluted with double its quantity 
of water and sweetened with sugar of milk, may be given every 
fourth hour, the babe being put to the breast in the meanwhile. 
So soon as the flow begins, however, the artificial feeding is to 
be discontinued. 

Usually on the fourth day milk is secreted and regular lacta- 
tion commences. Many untrained mothers make a failure of 
nursing because they know nothing of the manner of giving suck ; 
of the length of time the child should be kept at the breast; of 



62 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the proper time for, and interval between feeding, and of the 
importance of regularity. Upon these points the physician 
should give minute instructions. 

When giving the breast, the infant must be held partly on its 
side, on the right or left arm, according to the gland about to be 
drawn, while the mother must bend her body forward, so that 
the nipple may fall easily into the child's mouth, and steady the 
breast with the first and second finger of the disengaged hand, 
placed above and below the nipple. In case the milk runs too 
freely — a condition very apt to excite vomiting — the flow is 
easily regulated by gentle pressure with the supporting fingers. 
Each of the breasts should be drawn alternately, the contents of 
one being usually sufficient for a meal ; and a healthy child may 
be allowed to nurse until satisfied, when he will stop of his own 
accord, drop the nipple and fall asleep with milk still flowing 
over his lips. 

During the first six weeks the breast is required every second 
hour, from 5 a. m. until 11 p. m. At night the infant should be 
put in a crib by the mother's bed, or in an adjoining room, 
under the care of a competent nurse, and there remain quietly 
until the morning feeding. This secures the mother six hours 
of uninterrupted repose, a matter of great importance to her 
general health and consequent capacity for prolonged lactation. 
As to the infant, he may rebel at first, and wake and cry, so that 
it is necessary to quiet him with a little milk and water adminis- 
tered from a bottle ; but often after a few days, and certainly at 
the end of a week or two, the good habit of sleeping at night 
is formed, and there is no further trouble. 

Regularity in meal hours is even of more importance in early 
than in adult life, on account of the natural feebleness of diges- 
tion. To secure this, it is only necessary to have a little perse- 
verance, for infants are such creatures of habit that a short 
training brings them into the w T ay of expecting food only at cer- 
tain times, and, when healthy, they wake to suck the breast with 
almost the precision of the clock. While insisting upon this 
rule, one must recognize the fact that, although in the vast 



THE GENERAL MANAGEMENT OF CHILDREN. 6$ 

majority of instances a two-hours' interval is most suitable up to 
the second month, there is no absolute law as to the number of 
daily nursings. Some infants seem to need food less frequently, 
and it is best to respect their peculiarity and not force the breast 
upon them so long as they sleep well, do not fret when awake, 
and thrive generally. Others, again, may require it oftener, 
every hour and a half, perhaps, and once or twice at night. In 
these exceptional cases an appropriate schedule can only be made 
by close observation of individual characteristics. 

A common and most ruinous mistake is to resort to constant 
feeding as a means of pacifying crying. Babies certainly do cry 
from hunger, but just as frequently the crying results from colic, 
or from the discomfort and pain of indigestion. Every mother 
should be able to recognize the difference. The cry from hunger 
usually begins after a sound sleep. It is not peevish, and stops 
at the sight of the breast, when the infant rouses himself, pre- 
sents an expression of pleasure, clinches his hands and flexes his 
limbs. The cry of colic is violent and paroxysmal; the face is 
livid and wears an expression of suffering ; the abdomen is dis- 
tended and hard ; the hands and feet are cold ; the legs are 
drawn up or kicked violently about ; and an explosion of wind 
from the mouth or bowels ends the attack. A peevish cry, hot 
skin and sour breath attend indigestion. 

It stands without saying that the cry of hunger must be relieved 
by giving food ; but this is the very worst thing to do under 
other circumstances, for it both breaks up good habits and pro- 
duces serious mischief. The pain of colic and the discomfort 
of indigestion are chiefly due to the accumulation of flatus result- 
ing from the fermentation of food. Mothers soon learn, and 
unfortunately infants too, that the breast milk temporarily 
relieves suffering. This it does in the same way as any other 
warm liquid ; but, unlike a simple fluid, milk only adds more 
material to the already fermenting contents of the gastrointesti- 
nal canal, and every nursing is soon followed by more pain, 
until between crying and sucking and sucking and crying, the 
infant's life is passed in misery, if not cut short altogether. 



64 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Instead of continuous feeding, the plan for relief is to decrease 
the quantity of food by increasing the intervals between nursing 
and by abridging the time of lying at the breast, while medi- 
cines are employed to strike at the root of the evil. 

After the sixth week the interval between nursing may be 
slowly increased until, by the fourth month, it reaches three 
hours. During this period, also, the time of lying at the breast 
may be gradually lengthened, for the quantity of milk secreted 
and the child's appetite and capacity for food are all augmented 
as the days pass by. At the end of the sixth month, feeding 
every fourth hour suits some children well, but as a rule the 
three-hour interval must be adhered to from the fourth month to 
the end of lactation. 

Many authorities recommend additional artificial feeding, 
alternating with nursing, after the sixth or eighth month. Such 
a plan is perfectly proper, if the babe ceases to gain strength and 
flesh while on the breast. If otherwise, the maxim of not inter- 
fering with any course that is doing well is as applicable here as 
elsewhere, and the breast may be relied upon entirely until the 
time comes for weaning. 

Should additional nutriment be required, the food must be 
selected with due reference to age and prepared in the same 
manner as in regular hand-feeding. 

The date of weaning cannot be fixed for all cases, since it 
must depend upon two conditions, — the health of the mother 
and the development of the child. When the former continues 
to be robust and the child steadily grows and gains flesh, lac- 
tation can be prolonged until the tenth or twelfth month. If 
persevered in longer, the mother's strength begins to fail, her 
milk is lessened in quantity or becomes poor in quality, the 
child's nutrition suffers, and he grows pale, thin and flabby, and 
may develop the disease known as rickets. 

Change in the manner of feeding may be accomplished gradu- 
ally or suddenly. In gradual weaning, about four weeks are 
required to prepare for the absolute withdrawal of the breast. 
For instance, if suck be given every three hours, from 5 a. m. 



THE GENERAL MANAGEMENT OF CHILDREN. 65 

until iip. m., or seven times a day, there should be, during the 
first week of preparation, one artificial feeding and six nursings 
daily; during the second, two and five; during the third, four 
and three; during the fourth, six and one. Then the breast 
must be entirely withheld. Carefully prepared milk-food, admin- 
istered from a bottle, is the best substitute. At the age of tea 
months a mixture that ordinarily agrees well is : — 

Cream, f§ss. 

Milk, fgiv. 

Sugar of milk, gj. 

Water, f^iss. 

This is to be poured into a perfectly clean bottle, warmed in 
a water bath, and taken through a clean, plain rubber tip. 
Should the quantity (six fluidounces) be insufficient to satisfy 
the child's appetite, all the ingredients except the cream may be 
increased until the mixture measures eight or even twelve fluid- 
ounces, according to the demand. 

When such accidents as fever, disordered digestion, with 
vomiting and diarrhoea, or the actual cutting of one or more 
teeth occur during the period of preparation, the number of 
artificial feedings must be reduced, or the breast resumed until 
the disturbance be passed ; then the course may be begun again 
and carried to its completion. 

Usually there is little trouble in weaning infants in this way. 
Sometimes they become fretful under the change and may refuse 
food entirely for a day or more ; but a little determination on 
the part of the mother and the cravings of hunger will soon 
overcome this difficulty. 

Occasionally the child refuses to suck milk from a bottle or to 
drink it from a cup or spoon, in fact seems to object to any form 
of liquid food except that drawn from the mother, while at the 
same time he is eager for bread or other solid food. Under 
these circumstances prepare for each meal a moderate portion of 
either rice pudding or junket. After these have been taken for 
a day or two, add to each meal a little milk, reducing the 
6 



66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

amount of pudding or junket ; stir the whole together and feed 
from a spoon; next day still further reduce the solid and 
increase the liquid, and so proceed until finally a taste for milk 
is cultivated. 

Sudden weaning is not advisable unless, while the breast is 
being presented, there is an absolute refusal to take artificial 
food from either a bottle or a spoon. This is most apt to occur 
when food has been given too frequently, and when the breast has 
been used as a means to quiet crying. Sudden weaning is also to 
be recommended when the mother's health becomes so affected as 
to render any further sucking a positive peril to the child's life; 
attacks of erysipelas or of smallpox are instances in point. 

The physician is often forced to decide upon the advisability 
of premature weaning. His decision must be made cautiously 
and after thorough investigation of two propositions, namely : a, 
the effect of further lactation upon the health of the mother, and 
by the requirements of the child. 

a. Lactation being a physiological process is not a drain upon 
the systemic strength so long as the functions of nutrition are 
actively performed, but under other circumstances it very fre- 
quently becomes so. Premature weaning is necessary when the 
mother is attacked by any acute disease threatening dangerous 
temporary prostration, such as typhoid or typhus fever. A 
change must also be made if pulmonary consumption be devel- 
oped, or, being already present, rapidly advances under the 
drain of milk secretion. Ordinarily, however, the general con- 
dition that leads to withdrawal of the breasts is one of simple 
loss of strength and flesh on the part of the mother. 

Undoubtedly these indications often warrant the procedure, 
but every one who has seen much of children's practice must 
have met with many cases in which the advice to wean has been 
given carelessly and unnecessarily, and in which the child might 
have had its natural food had proper attention been given to the 
health of the mother. 

If a woman be worn out by household cares ; if she wear her- 
self out by a round of dinners, balls or shopping, or if she 



THE GENERAL MANAGEMENT OF CHILDREN. 6 J 

expose herself to injurious atmospheric conditions and eats im- 
proper food, she grows weak and thin whether she be nursing or 
not ; and a woman heedless of her health will probably care 
little whether she suckles her child or gives it up to a wet-nurse 
or to the bottle. 

In addition to making nursing the important duty of her life 
for the time being, a mother must be as free from household cares 
as possible. Mental and physical fatigue is to be avoided, 
sufficient exercise must be taken to maintain a healthy appetite 
and digestion, and abundant time devoted to rest and sleep. 
Beyond securing a plentiful supply of plain and easily digestible 
food, with a judicious- portion of meat, vegetables, and fruit, it 
is unnecessary to give special attention to the diet. 

Should the secretion of milk be scanty, it may often be increased 
by the free use of animal broths, chocolate, gruel, or milk, and 
sometimes the moderate employment of stimulants, in the form 
of ale and porter, may be necessary. Such tonics as malt extract, 
ferrated elixir of cinchona, bitter wine of iron, and the prepa- 
ration known as "beef, wine and iron," are useful when there is 
anaemia, or when the general failure of strength cannot be over- 
come by food and attention to hygienic rules. 

The ordinary local conditions indicating the necessity of pre- 
mature weaning, on the mother's account, are fissures of the 
nipple and mammary abscess. 

Fissure being usually a unilateral condition, it is only necessary 
to retire the affected side from duty and nourish the child alter- 
nately from the unaffected gland and from the bottle until healing 
takes place, the disabled breast being pumped in the meantime 
to keep up secretory activity. Should both sides be affected, 
weaning may be imperative, on account of the extreme pain pro- 
duced by sucking, though, even under these circumstances, an 
effort must be made to maintain the flow of milk by regular pump- 
ing. Sometimes women are able to struggle through the attack 
by taking advantage of the relief and protection afforded by a 
nipple-shield. 

Fissures of the nipple may be preceded by various diseases of 



68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the delicate skin of the part. They result, also, from want of 
cleanliness or from keeping the nipple too moist, as when con- 
stant sucking is allowed or when there is a continual flow of milk. 
They may be prevented by proper attention to the nipple before 
confinement. During the latter months of pregnancy the clothing 
covering the breast must be loose, and the wearing of a wire tea- 
strainer over the nipple to prevent pressure has been recommended 
by one authority. Each day for three months before labor, the 
nipples should be washed thoroughly with hot water in the even- 
ing and anointed with cocoa-butter in the morning. At the same 
time, should the nipples be small or retracted, the woman must 
be taught to use her thumb and finger to draw them out. This 
process is not only an advantage in giving proper size and shape, 
but brings the skin into good condition without hardening it. 
The application of alcoholic and astringent lotions is not to be 
recommended. They tend to harden the tissue, which should be 
soft and pliable rather than tanned, and render the nipples liable 
to crack. 

When a fissure exists, it is best first to see whether or not 
nursing can be continued by means of a nipple-shield. Should 
the child refuse this, a good plan is to fill the shield with warm 
milk and invert it over the nipple. The infant then draws the 
fluid at once and without difficulty, and will often continue 
sucking until the breast milk follows. After nursing and re- 
moving the shield, the nipple must be dried thoroughly with 
absorbent cotton, and the following lotion applied with a 
camel's-hair brush : — 

R. Acid. Boracic, gr. xx. 

Mucilag. Acaciae, f^j- M. 

b. On the part of the infant, there are several indications for 
anticipating the time of withdrawing the mother's breast. It 
must be done if the occurrence of pregnancy or the recurrence 
of menstruation render the milk unwholesome ; if the mother 
contract a dangerous contagious disease, as smallpox, scarlet 
fever, or erysipelas ; if the mammary glands become inflamed ; if 



THE GENERAL MANAGEMENT OF CHILDREN. 69 

the breast does not afford sufficient nourishment and artificial 
food be refused; and, finally, if "dentition be markedly delayed 
and the premonitory symptoms of rickets appear. As to the 
amount of nourishment, it must be remembered that the breast 
milk may be of good quality, but so diminished in quantity that 
it is insufficient; or, while abundant in quantity, so poor in 
quality that it does not meet the demands of nutrition. Even 
without a minute examination of the milk, it is possible to form 
a good idea of which condition is present from the behavior of 
the infant in the act of sucking. If the milk be good in quality 
but deficient in quantity, the babe, when put to the breast, seizes 
the nipple as if famished, and draws upon it vigorously for a time, 
and then drops it with a scream of rage. On the contrary, 
should there be an abundant supply of poor milk, the nipple is 
grasped languidly, the child lies a long time at the breast and 
falls asleep there. Consideration of the final indication opens 
the question of the propriety of regulating weaning by the pro- 
gress of dentition. This is certainly a good guide, but not in 
the way implied in the old precept, that the child must not be 
taken from the breast until evolution of the stomach and eye 
teeth. Insufficient food is one of the chief causes of rickets, and 
rickets more than any other disease delays dentition ; conse- 
quently, should the teeth not pierce the gum in time, the infer- 
ence is for other food rather than a continuance of the faulty 
maternal supply. 

Upon deciding to anticipate the time of weaning, the next 
point to consider is whether the infant shall be brought up by 
hand or by a wet-nurse. 

2d. Feeding by a wet-nurse. The advantage of feeding from 
the breast of a wet-nurse is that the mother's milk is substituted 
by the milk of another woman ; in other words, that natural 
feeding is continued — a matter of moment in all cases, and of 
inestimable importance with delicate children. The disadvan- 
tage consists in the difficulty of finding, in a woman belonging 
to the class from which wet-nurses come, all the moral and 
physical characters essential to a good substitute, and in the fact 



70 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

that a stranger is introduced into the household, often to deceive 
and annoy the family, and on the slightest provocation to leave 
her charge to fate or to the tender mercies of another of her 
kind. For these reasons it is preferable, in the majority of in- 
stances, to trust to careful bottle-feeding. Nevertheless, as some 
children must have human milk if their lives are to be saved, 
the rules for selecting a wet-nurse must be understood. 

The woman chosen must be strong and robust, but rather 
spare than fat. Her bill of health must be perfectly free from 
hereditary tendency to mental or physical disease and from taint 
of syphilis, consumption or scrofula. She must be cheerful, 
good-natured, active, careful, and temperate in habits. Her age 
should be between twenty and thirty years ; she should under- 
stand the care of an infant and the manner of giving suck ; her 
child ought to be nearly the same age as the infant to be adopted, 
and she must be able to afford an abundant supply of good 
milk. 

The last quality can be estimated by inspecting the breasts, 
by examining some of the milk drawn by a pump, and by ascer- 
taining the condition of the woman's own child. The breasts of 
a good nurse are not necessarily large, but are firm to the touch 
and pyriform in shape, with well-developed, prominent nipples, 
and with the skin distinctly marbled with large blue veins. The 
milk, which ought to flow readily on pressure or on suction, 
should be opaque and dull white in color, have a specific gravity 
of i. 031, an alkaline reaction, and show, when placed under the 
microscope, a number of minute, equal-sized, fat globules. Its 
quantity may be ascertained by weighing the child before and 
after sucking, the normal gain being from three to six ounces. 
There is, however, no better or more readily applied test of the 
quality of a nurse than the size, weight, and general development 
of her own child ; and if it be weak and ill-nourished, no amount 
of fitness in other respects can warrant her engagement. 

Even when a woman is found fulfilling in her single person 
all the required conditions — a rare thing, indeed — it does not 
necessarily follow that her milk will suit the babe to be suckled. 



THE GENERAL MANAGEMENT OF CHILDREN. . 7 1 

Then changes and new trials must be made until the desired end 
be attained. 

The diet of a wet-nurse and the manner of weaning, must be 
governed by the rules already given for maternal guidance. 

Personally, I have had such good results from carefully regu- 
lated bottle-feeding, that I have almost given up the employment 
of wet-nurses, preferring to regulate the artificial food myself 
rather than allow an ignorant woman to supplement surreptitiously 
her deficient supply of breast milk by an unskilfully proportioned 
food, — an event of not uncommon occurrence. 

3d. Artificial feeding. In my experience, there are few 
American women, especially in the well-to-do classes, who do 
not look upon the duty of nursing their babies as a pleasant one ; 
but there are many who are completely unable to do so, and a 
vast number in whom the secretion of milk fails after a few weeks 
or months of lactation. They must, therefore, through no fault of 
their own, resort to a wet-nurse or to artificial feeding. Usually, 
they select the latter method, with results that vary in direct pro- 
portion to the care and intelligence displayed in carrying it out. 
There is no artificial food equal to the milk of a robust woman. 
The fluids however, secreted from the glands of a feeble or un- 
healthy mother, though often sufficient in quantity to fill the 
suckling's stomach and satisfy the cravings of hunger, does not 
contain enough pabulum to meet the demands of nutrition. In 
such unfortunate cases, good cows' milk, properly prepared, is a 
better food than the bad breast milk. More care and trouble, 
though, are involved in bottle than in breast feeding. If the 
child has been nourished in the natural way — L e. 9 breast- 
fed — even for a few weeks, or when the powers of digestion are 
inherently active, the task is far easier to accomplish. In these 
cases the stomach and intestinal canal, inactive in fcetal life, are 
trained to their new duties under normal conditions, and so pre- 
pared for the digestion of properly selected artificial food. On 
the contrary, if digestion be naturally feeble, or if the infant 
must be bottle-fed from the first, great difficulty may be expected, 
and most skilful handling is necessary. 



72 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

To insure success in hand-feeding, it must be remembered 
that an infant is not nourished alone by the food he swallows, 
but by that portion of it he digests and assimilates. The best 
diet, therefore, is one so adapted to age and digestive power 
that everything eaten will be digested and absorbed. But as 
children differ as much in constitution as in feature, it is im- 
possible to formulate exactly a food that will be applicable to 
every case, or one that needs no change from month to month 
of progressing growth. As age and strength increase, there is a 
corresponding development of the gastro-intestinal functions and 
a demand for more and stronger food. On the other hand, 
should the system be accidentally reduced by disease, the diges- 
tion, sympathizing in the general debility, temporarily loses its 
normal activity and assumes that of an earlier age. In such a 
case more nourishment is certainly needed to build up the failing 
strength, but it is to be supplied by giving such food as can be 
completely assimilated, and not by forcing down strong food 
merely because it is strong; for the latter, when not vomited, 
passes through the bowels undigested, and the little creature 
starves to death in the midst of plenty, or dies from the ill effects 
of the constant presence of fermenting food in the alimentary 
canal. On these accounts many changes in diet, as to quality 
and quantity, must be anticipated and made. 

Important matters, therefore, to be studied in detail are : a> 
the selection of a proper substitute for the breast milk ; b, the 
quantity to be given ; c, the method of preparation ; d, the mode 
of administration ; and, e, the means of preservation. 

a. Healthy breast milk must be taken as the type of infants' 
food, and the nearer an artificial substance can be made to ap- 
proach it in chemical composition and physical properties, the 
more perfect it is. 

Normal breast milk has a specific gravity of 1.031. It is a 
persistently alkaline fluid, having a somewhat animal, usually 
disagreeble, and very rarely sweetish taste. It is bluish-white in 
color and thin and watery in consistence. 



THE GENERAL MANAGEMENT OF CHILDREN. 73 

According to Leeds' very thorough analysis, it contains : — 

Water, 86.766 per cent. 

Total solids, 13. 234 

Total solids not fat, 9.221 

Fat, 4.013 

Milk sugar, 6.997 

Albuminoids, 2.058 

Ash, 0.21 

It contains, then, nitrogenous material, carbohydrates, salts 
and water — all the elements essential to repair tissue waste, to 
supply new material for growth and to maintain body heat, or, 
in other words, to constitute a perfect aliment ; and these, too, 
are so proportioned in the combination as to most easily and 
completely meet the demands. 

It must not be supposed, however, that the elements are uni- 
formly present in the same proportion. On the contrary, the 
fluid varies both at different periods of lactation and in different 
individuals. 

This fact is the most striking feature of the above observer's 
work, which shows that the most changeable constituent is the 
albumen, varying from a maximum of 4.86 per cent, to a mini- 
mum of 0.85 ; the next are the fats and salts, the maximum 
being about three times the minimum, and the least the sugar. 
The latter, in fact, varies but little from a standard of about 7 per 
cent. The function of albumen is nutritive ; that of milk sugar 
calorifacient ; hence the point seems to be that nature, while 
allowing a wide range of oscillation in the rapidity of tissue 
building, carefully provides an available fuel for the constant 
maintenance of animal heat ; the supply of caloric due to cere- 
bral impulses and self-originated locomotion being extremely 
small in early infancy. 

In seeking a substitute for human milk, one naturally turns to 
the domestic animals for the source of supply. Between the milk 
of the ass, cow, goat and ewe there is little choice, so far as com- 
position is concerned, though, perhaps, asses' milk resembles 
that of women a little more closely than the others ; nevertheless, 



74 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



cows' milk is usually selected, because, being plentiful, it is easily 
obtained and cheap. 

Cows' milk* (market milk) has a specific gravity of 1.029, is 
richer looking — that is, whiter and more opaque than human 
milk, and is slightly acid in reaction unless perfectly fresh from 
pasture-fed animals, when it may be neutral or alkaline, and 
contains — 

Water, 87.7 per cent. 

Total solids, 1 2.3 

Total solids not fat, 8.48 

Fat, 3.75 

Milk sugar, 4.42 

Albuminoids 3.42 

Ash, 0.64 

Comparing this analysis with that previously given, it is 
readily seen that the two fluids differ in specific gravity and reac- 



FlG. I. 



* The characters of cow's milk may be determined with sufficient accuracy 
in the following way : — 

Provide a urinometer, such as shown in Fig. I, and 
which can be obtained at any drug shop. To obtain the 
specific gravity, fill the beaker to such a point with milk 
that it will float the specific gravity glass, and read the 
degree of density from the scale at a level with the sur- 
face of the milk. The chemical reaction is found by 
inserting a piece of blue litmus paper, which should 
turn slightly red a few moments after being wet. In ap- 
plying this test small pieces of litmus paper should be 
examined under and in the milk, as exposure to air may 
redden paper dipped in milk though the fluid itself may 
not be acid. To ascertain the proportion of cream, cut a 
narrow strip of paper four inches long, and divide the 
upper half-inch, by cross-markings, into twelve equal 
parts ; paste this on the beaker with the marked portion 
uppermost, and the lower edge coming accurately to the 
bottom of the beaker; then pour in enough milk to 
come just to the top of the paper, and place the whole aside for twenty-four 
hours. During, this time the cream rises and appears as a yellow layer at the 



d 



b 



LACTOMETER. 



top; this layer should have the depth of ten or twelve spaces. 



THE GENERAL MANAGEMENT OF CHILDREN. 75 

tion, and that cows' milk contains more nitrogenous material, 
but less fat and much less sugar than woman's milk. 

The nitrogenous material differs in quality as well as in quan- 
tity. Konig, in a number of analyses that closely correspond 
with those of Leeds, divides the nitrogenous constituent into 
three groups; namely, caseine, albumen and albuminoids, basing 
the division upon the different effects of coagulating agents. 

Upon this point Leeds remarks : " Whilst by present modes of 
analysis the separation of the so-called caseine from the so-called 
albumen is not accurately performed, yet the results are approxi- 
mately correct (Konig's), and have a very great value in point- 
ing out the most important of all the differences between the 
two secretions, which is, that the fraction of the total albu- 
minoids in cows' milk which is coagulable by acids is far greater 
(perhaps four times) than the non-coagulable part. 

"In woman's milk, on the contrary, the reverse is true, and 
the non-coagulable part much exceeds (perhaps by more than 
twice) the coagulable portion." 

This difference is readily tested by adding rennet to the two 
fluids. In the case of cows' milk the caseine is coagulated into 
large, firm masses, while with human milk a light, loose curd 
is formed. In the stomach the acid gastric juice has the same 
effect, producing in the first instance a coagulum most difficult to 
digest j in the other, one readily attacked and broken down by 
the gastro-intestinal solvents. 

These chemical and physical properties of cows' milk can be 
altered by various methods of preparation, and unless this be done 
there are few instances in which it will not prove a poor substi- 
tute for the natural food. 

Condensed milk is frequently recommended by physicians and 
largely used by the laity, on their own responsibility. It keeps 
better than cows' milk and is supposed to be more readily 
digested by young infants. The latter supposition is a mistaken 
one, and arises from the overlooked fact that condensed milk is 
always given dissolved in a large proportion of water, while cows' 
milk is too frequently used insufficiently diluted or otherwise im- 



76 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

properly prepared. The author is convinced of the accuracy of 
this statement from a number of years' close study of the subject. 

Condensed milk contains a large proportion of sugar, forms fat 
quickly, and thus makes large babies; sugar also counteracts the 
tendency to constipation — often a troublesome complaint in 
hand-feeding. These advantages are unquestioned, and, together 
with the ease of preparation, are those which place it so high in 
the esteem of monthly nurses. It is equally true, however, that, 
as a food, it does not contain enough nutrient material to supply 
the wants of a growing baby. 

Again, more than half of the saccharine ingredient of this 
preparation is cane sugar, added for the purpose of preservation, 
and this material is very liable, when in excess, to ferment in 
the alimentary canal, giving rise to irritant products that impede 
digestion. 

Infants fed upon condensed milk, though fat, are pale, leth- 
argic and flabby ; although large, they are far from strong ; have 
little power to resist diseases ; often cut their teeth late, and are 
very liable to drift into rickets. It must be remembered also 
that condensed milk, when long kept, or when packed in imper- 
fect cans, not unfrequently undergoes decomposition, and thus 
becomes utterly unfit for use. 

For a temporary change of diet, and as a substitute during 
travelling or under circumstances in which sound cows' milk 
cannot be obtained, it may be resorted to with advantage. 

The farinaceous substances so often selected, especially by the 
poor, to replace breast-milk, are not only bad foods, but have 
both directly and indirectly a deleterious effect upon the pro- 
cesses of nutrition. 

They are bad for two reasons. First, they differ materially in 
chemical composition from human milk. For example, in arrow- 
root, which is the favorite, the proportion of the tissue-building 
to the heat-producing element is as one to twenty, while in human 
milk it is about one to five. Secondly, the heat-producing prin- 
ciple, starch, must be converted into sugar before it can be 
absorbed. This change is accomplished in the body by the 



THE GENERAL MANAGEMENT OF CHILDREN. 77 

saliva and pancreatic juice, — secretions that are not fully estab- 
lished until the fourth month. 

While the starch lies undigested in the gastro-intestinal canal, 
it is subject to fermentation, resulting in the formation of irritant 
products that rapidly induce catarrh of the mucous membrane ; 
a condition directly interfering with the digestion and absorption 
of food. Again, perfect nutrition demands rapid waste and 
removal of effete tissues as well as repair of the same. This is 
effected by oxidation. Now sugars are known to have a much 
greater affinity for oxygen than albuminates, and when the diet 
consists of farinaceous material, the small amount of sugar formed 
and absorbed appropriates oxygen that otherwise would go toward 
the removal of waste, and so retards the necessary changes. 

Farinaceous food, as such, is never permissible before the 
fourth month; earlier, it is only to be employed for its me- 
chanical action, as an addition to milk preparations. This will 
be mentioned later. 

The nutrient value of the cereals and their products as they exist 
in so-called "infants' foods," has been imperfectly determined. 
They are undoubtedly useful as mechanical attenuants, but it is 
very questionable whether any of them, unless prepared with 
milk, can permanently meet the demands of nutrition. At the 
same time it is quite probable that the soluble albuminoid sub- 
stances obtained by Liebig's process have a food value of their 
own, making them more serviceable than the starches. 

b. The quantity of food to be allowed each day varies with 
the appetite and age. Some infants habitually eat little, others 
much ; as both thrive, the question of the correct amount in a 
given case must be answered by observation. So long as the 
child develops with normal rapidity and keeps well, he may be 
allowed to eat as much or as little as he wants ; for, if food of 
proper strength be given at proper intervals, the instinctive 
cravings of hunger, since they represent the wants of the system, 
rarely lead to excess in either direction. Nevertheless it is well 
to have some guide. 



78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

During the first four weeks, infants generally require from 
twelve and-a-half to sixteen fluidounces of food j in the second and 
third months, about twenty-four fluidounces, and from this time to 
the twelfth month from two to two and-a-half or even three pints. 
After the twelfth month the quantity depends upon whether addi- 
tions be made to the diet, or milk food be used exclusively. 
When the daily amount reaches three pints, the limit of the 
capacity of the stomach is usually attained, and the greater 
demand for nutriment, as growth advances month by month, 
must be met by adding to the strength of the food rather 
than by increasing its bulk. These two factors, strength 
and quantity, are intimately associated throughout the whole 
period of infancy, and in the earlier months a mere increase 
in the latter is not always sufficient to maintain the balance of 
nutrition. 

As a rule, infants are overfed, and this opens the very inter- 
esting question of the normal capacity of the stomach at different 
ages. Rotch has recently written an important paper upon the 
subject. He states that, by actual measurement, the stomach 
of an infant five days old holds 25 c.c, or six and-a-quarter 
fluidrachms, a quantity very far short of that usually forced upon 
the babe during the first week. Frowlowsky's investigations 
show that there is a very rapid increase in the capacity of the 
stomach during the first two months of life, while in the third, 
fourth and fifth months the increase is slight. Guided by 
these data, the quantity of food should be rapidly augmented 
during the first six or eight weeks of life and then held at the 
same quantity up to the fifth or sixth month. Another con- 
siderable increase is also demanded between the sixth and the 
tenth months. 

While the author has been unable to verify the above measure- 
ments, and has, on the contrary, found no uniformity in the size 
of the stomach for given ages, yet the following table (Rotch) 
is a useful one, and corresponds closely with conclusions drawn 
from clinical experience. 



THE GENERAL MANAGEMENT OF CHILDREN. 
GENERAL RULES FOR FEEDING. 



79 



Age. 


Intervals of 
Feeding. 


Average Amount at 
Each Feeding. 


Average Amount in 
24 Hours. 


First week. 


2 hours. 


i ounce. 


10 ounces. 


One to six weeks. 


2% hours. 


1% to 2 ounces. 


12 to 16 ounces. 


Six to twelve weeks 
and possibly to fifth or 
sixth month. 


3 hours. 


3 to 4 ounces. 


18 to 24 ounces. 


At six months. 


3 hours. 


6 ounces. 


36 ounces. 


At ten months. 


3 hours. 


8 ounces. 


40 ounces. 



c. The object to be accomplished in the preparation of cows* 
milk is to make it resemble human milk as much as possible in 
chemical composition and physical properties. To do this, it 
is necessary to reduce the proportion of caseine, to increase the 
proportion of fat and sugar, and to overcome the tendency of 
the caseine to coagulate into large, firm masses upon entering the 
stomach. 

Dilution with water is all that need be done to reduce the 
amount of caseine to the proper level ; but as this diminishes 
the already insufficient fat and sugar, it is essential to add these 
materials to the mixture of milk and water. Fat is best added in 
the form of cream, and of the sugars, either pure white loaf sugar 
or sugar of milk may be used. The latter is greatly preferable, 
as it is little apt to ferment, and contains some of the salts of 
milk, which are of nutritive value. 

Firm clotting may be prevented by the addition of an alkali 
or a small quantity of some thickening substance. 

Lime water is the alkali usually selected. It acts by partially 
neutralizing the acid of the gastric juice, so that the caseine is 
coagulated gradually and in small masses, or passes, in great part, 
unchanged into the intestine, to be there digested by the alkaline 



80 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

secretions. As it contains only half a grain of lime to the fluid- 
ounce, the desired result cannot be attained, unless at least a third 
part of the milk mixture be lime water. The quantity often 
used — one or two teaspoonfuls to the bottle of food — has no 
effect beyond neutralizing the natural acidity of the milk itself. 
When lime water is constantly employed, it becomes quite an 
item of expense if procured from the drug shop; this outlay is 
unnecessary, for it can be made quite as well in the nursery. 
Take a piece of unslaked lime as large as a walnut, drop it into 
two quarts of filtered water contained in an earthen vessel, stir 
thoroughly, allow to settle, and use only from the top, replacing 
the water and stirring as consumed. 

Instead of lime water, two to four grains of bicarbonate of 
sodium may be added to each bottle, or, better still, from five 
to fifteen drops of the saccharated solution of lime. 

This solution is made in the following way : — 

Take of — 

Slaked lime, t ounce. 

Refined sugar, in powder, 2 ounces. 

Distilled water, I pint. 

Mix the lime and sugar by trituration in a mortar. Transfer the mixture to 
a bottle containing the water, and having closed this with a cork, shake it 
occasionally for a few hours. Finally, separate the clear solution with a 
siphon and keep it in a stoppered bottle. 

Thickening substances — attenuants, such as barley-water, gela- 
tine, or one of the digestible prepared foods — act purely me- 
chanically by getting, as it were, between the particles of caseine 
during coagulation, preventing their running together and form- 
ing a large, compact mass. 

To prepare the former, put two teaspoonfuls of washed pearl 
barley, with a pint of cold filtered water, into a saucepan, boil 
slowly down to two-thirds and strain. The liquid obtained does 
not possess the disadvantages of farinaceous foods generally. To 
be efficient, it must be used as a diluent instead of, and in the 
same proportion as, water. 

Gelatine is prepared in the following way : put a piece of plate 



THE GENERAL MANAGEMENT OF CHILDREN. 8 1 

gelatine, an inch square, into a half-tumblerful of cold water, and 
let it stand for three hours ; then turn the whole into a teacup, 
place this in a saucepan half full of water and boil until the 
gelatine is dissolved. When cold this forms a jelly; from 
one to two teaspoonfuls may be added to each bottle of milk 
food. 

When an " infant's food " is used to act mechanically, care 
should be taken to select one in which the starch has been con- 
verted into dextrine and grape sugar by the process of manufac- 
ture. The articles known as " Mellin's Food " and " Horlick's 
Food " can be relied upon. One teaspoonful of either dissolved 
in a tablespoonful of hot water and added to each portion of food, 
makes a very easily digested mixture. 

For the successful management of children, the mother or 
nurse must not only be familiar with the theory of feeding, but 
must practically understand the methods of preparing food. To 
this end a schedule of the diet of an infant from birth upward, 
with a sketch of the modifications that have to be made most fre- 
quently, will serve as a useful guide. 

Diet during the first week : — 

Cream, f ^ ij. 

Whey, . fgiij. 

Water (hot), f^iij- 

Milk sugar, gr. xx. 

For each portion; to be given every two hours from 5 A. m. to II p. M., and 
in some cases once or twice at night ; amounting to twelve fluidounces of 
food per diem. 

Diet from the second to the sixth week : — 

Milk, fgss. 

Cream, f^ij. 

Milk sugar, gr. xx. 

Water, fgj. 

For one portion; to be given every two hours from 5 A. m. to 11 P. M.; 
amounting to seventeen fluidounces of food per diem. 

7 



82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diet from the sixth week to the end of the second month : — 

Milk, f'2j,fgij. 

Cream, f^ss. 

Milk sugar, g ss. 

Water, (EhW* 

For each portion; to be given every two hours; amounting to thirty fluid- 
ounces per diem. 

Diet from the beginning of the third month to the sixth 
month : — 

Milk, f^iiss. 

Cream, ^3 SS - 

Milk sugar, ^j. 

Water fgj. 

For each portion; to be given every two and a half hours, or thirty-two 
fluidounces per diem. 

Diet during the sixth month ; six meals daily from 6 or 7 
a. m. to 9 or 10 P. M. 

Morning and midday bottles each : — 

Milk, f 3 ivss. 

Cream, f^ss. 

Mellin's Food, 3J. 

Hot water, f§j. 

Dissolve the Mellin's F\)od in the hot water and add, with stirring, to the 
previously mixed milk and cream. 

Other bottles each : — 

Milk, f g ivss. 

Cream, *\5 SS - 

Milk sugar, ^j. 

Water, fgj. 

This gives an equivalent of thirty-six fluidounces of food in a 
day. 

In the seventh month the Mellin's Food may be increased to 
two teaspoonfuls and given three times daily. 



THE GENERAL MANAGEMENT OF CHILDREN. 8$ 

Throughout the eighth and ninth months five meals a day will 
be sufficient. 

First meal at 7 a. m. : — 

Milk, f^viss. 

Cream, f J ss. 

Milk sugar, ^j. 

Water, fgj. 

Second meal at 10.30 a. m. Milk, cream and water in the 
same proportion \ Mellin's Food, one tablespoonful. 

Third meal at 2 p. m. — Same as second. 

Fourth meal at 6 p. m. — Same as second. 

Fifth meal at 10 p. m. — Same as first. 

This gives forty fluidounces of food per diem. 

Instead of Mellin's Food, a teaspoonful of " flour-ball " * may 
be added. 

Two meals of flour-ball daily — the second and fourth — are all 
that can be digested. To prepare these, rub one teaspoonful of 
the powder with a tablespoonful of milk into a smooth paste, then 
add a second tablespoonful of milk, constantly rubbing until a 
cream-like mixture is obtained. Pour this into eight ounces of 
hot milk, stirring well, and it is then ready for use. The other 
meals should be composed of milk, cream, sugar of milk and 
water, as already given. 

Mellin's Food and flour-ball may be substituted by oatmeal or 
barley, or any one of the infants' food in which the starch has 
been converted, by Liebig's process, into dextrine and grape 
sugar. 

* To make flour-ball, take a pound of good wheat flour — unbolted, if 
possible — tie it up very tightly in a strong pudding-bag, place it in a saucepan 
of water and boil constantly for ten hours; when cold, remove the cloth, cut 
away the soft, outer covering of dough that has been formed, and reduce the 
hard-baked interior by grating. In the yellowish- white powder obtained, almost 
all the starch has been converted into dextrine by the process of cooking, and 
the proportion of the nitrogenous principle to the calorifacient is as one to five, 
nearly the same as human miik. 



84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diet for the tenth and eleventh months : — 
First meal, 7 a. m. : — 

Milk, f g viiiss. 

Cream, f3 ss * 

Mellin's Food, g ss. 

(Or flour-ball or barley jelly), gij. 

Water (used only with Mellin's Food), fgj. 

Second meal, 10.30 a. m. — A breakfast-cupful of warm milk 
(eight fluidounces). 

Third msal, 2 p. m. — The yelk of an egg lightly boiled, with 
stale bread crumbs. 

Fourth meal, 6 p. m. — Same as first. 

Fifth meal, 10 p. m. — Same as second. 

On alternate days the third meal may consist of a teacupful 
(six fluidounces) of beef tea* containing a few stale bread crumbs. 

A further variation can be made by occasionally using mutton, 
chicken or veal broth instead of beef tea. 

As much more difficulty is experienced in feeding infants 
during the first twelve months than during the second, it would 
be well to pause here to consider what had best be done in case 
the food described should disagree. 

If, after feeding, vomiting occur, with the expulsion of large, 
firm clots of caseine, the effect of adding lime water or barley 
water must be tried. 

For instance, at the age of six weeks, make each bottle of: — 

Miik, f3ifWJ- 

Cream, f^ss. 

Milk sugar, 3 ss. 

Lime water, f Jj, f gij. 



* Beef tea for an infant is made in the following way : Half a pound of 
fresh rump-steak, free from fat, is cut into small pieces and put, with one pint 
of cold water, into a covered, tin saucepan. This must stand by the side of 
the fire for four hours, then be allowed to simmer gently (never boil) for two 
hours, and, finally, be thoroughly skimmed to remove all grease. 



THE GENERAL MANAGEMENT OF CHILDREN. 85 

Or of:— 

Milk fgj,f3ij. 

Cream, f^ss. 

Milk sugar, g ss. 

Barley water, fgj, f^ij. 

Sometimes, particularly if there be diarrhoea, boiling makes 
the milk more tolerable, and in this condition it may be used 
instead of fresh milk in either of the above mixtures. Con- 
densed milk, too, can be employed temporarily, making each 
portion of: — 

Condensed milk, gj. 

Cream, ■ . . . f g ss. 

Hot water, fgiiss. 

Should further alteration be necessary, goats' or asses' milk 
maybe substituted for cows' milk, the strong odor of the former 
and the laxative properties of the latter being removed by boil- 
ing. One ass is capable of nourishing three children for the first 
three months of life, two children for the fourth and fifth months, 
and one child after this period to the ninth month. The milk 
should be used warm from the udder. 

" Strippings " is another good substitute for cows' milk. It is 
obtained by re-milking the cow after the ordinary daily supply 
has been drawn, and contains much cream and but little curd. 
Assimilable proportions of this are : — 

Strippings, fgj. 

Water, f Jij. 

And if the small amount of caseine, in such a mixture, be still 
undigested : — 

Strippings, f^iss. 

Barley water, fgiss. 

Another good food is that recommended by Dr. A. V. Meigs. 
It consists of a combination of two parts of the cream, contain- 
ing from fourteen to sixteen per cent, of fat ; one part average 



86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

milk; two parts lime water, and three parts sugar water, the 
latter consisting of seventeen and three-fourths drachms of milk 
sugar to one pint of water. This makes an alkaline mixture with 
the percentage of its ingredients closely corresponding to human 
milk. 

When, in spite of careful preparation, all of .these foods give 
rise to indigestion with fever, and the expulsion, by vomiting and 
diarrhoea, of hard curds from the stomach and intestines, the 
expedient of predigesting the milk must be resorted to. 

The best method is to peptonize the milk by pancreatin. That 
manufactured under the name of extractum pancreatis, by Fair- 
child Brother & Foster, of New York, has proved most efficient 
in my hands. To accomplish this artificial digestion, put into a 
clean quart bottle five grains of extractum pancreatis, fifteen 
grains of bicarbonate of sodium, and four fluidounces of cool, 
filtered water; shake thoroughly together, and add a pint of 
fresh, cool milk. Place the bottle in water, not so hot but that 
the whole hand can be held in it for a minute without discom- 
fort, and keep the bottle there for exactly thirty minutes. At the 
end of that time put the bottle on ice to check further digestion 
and to keep the milk from spoiling. The fluid obtained, while 
somewhat less white in color than milk, does not differ from it 
in taste ; if, however, an acid be added, the caseine, instead of 
being coagulated into large, firm curds, takes the form of minute, 
soft flakes, or readily broken-down feathery masses of small size. 
When the process is carried just to the point described, the case- 
ine is only partly converted into peptone ; but every succeeding 
moment of continued warmth lessens the amount of caseine until 
peptonization is complete. Then the liquid is grayish yellow in 
color ; has a distinctly bitter taste, and shows no coagulation 
whatever on the addition of an acid. This artificial digestion, 
therefore, may be carried just as far as circumstances indicate, 
although it is ordinarily best to stop it short of complete conver- 
sion, as children object to the markedly bitter taste, and often, 
on account of it, absolutely refuse the food. Partial peptoniza- 
tion, too, is usually sufficient to adapt the milk to ready assimila- 



THE GENERAL MANAGEMENT OF CHILDREN. 87 

tion. To seize the proper moment for arresting the process, the 
person conducting it must be told to taste the milk from time to 
time, and as soon as the least bitterness is appreciable, to remove 
the bottle from the hot water and place it upon ice for cooling 
and use. Such milk may be sweetened with sugar of milk, and 
given pure or diluted with water. For an infant of six weeks 
each meal may consist of: — 

Peptonized milk, f g iij. 

Milk sugar, gss. 

Water, fgj. 

To this, cream may be added when desirable, and by dimin- 
ishing the quantity of water and increasing that of milk the 
strength of the food may be made greater at any time. 

Although every precaution be taken, the last of a quantity of 
predigested food is very apt to grow bitter ; and if the attend- 
ants will take the trouble, it is much better to peptonize every 
meal separately. This is readily done by obtaining a number of 
powders of pancreatin and bicarbonate of sodium, so proportioned 
that each packet shall contain the proper amount for one bottle 
of food. 

For example : — 

R . Extract. Pancreatis, , gr. ix. 

Sodii Bicarb., gr. xxiv. 

M. et ft. chart., No. xij. 
Sig. — Put one powder into a nursing bottle with two fluidounces of filtered 
water and two fluidounces of fresh sweet milk ; shake together and keep 
warm in a water-bath for about half an hour before feeding ; sweeten with 
half a teaspoon ful of milk sugar. 

The great advantages of partial peptonization are that the 
necessity for lime water, barley water and thickening substances 
to keep apart the curd is done away with, and that, when the 
digestive disturbance requiring a careful preparation of food is 
removed, an ordinary milk diet can be gradually resumed by 
regularly diminishing the time artificial digestion is allowed to 
progress. This changes the caseine in a less and less degree, 
until, finally, it is taken in its natural form. 



88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Instead of this ordinary peptonizing process, I have for several 
years past employed the " Peptogenic milk powder," prepared 
by the chemists already referred to This powder contains a 
digestive ferment, pancreatin ; an alkali, bicarbonate of sodium, 
and a due proportion of milk sugar. 

The mode of employment is as follows : — 

Take of— 

Milk, fgij. 

Water, fgij. 

Cream, gss. 

Peptogenic milk powder, I measure.* 

This mixture is to be heated over a brisk flame to a point that 
can be comfortably sipped by the preparer (about 115 F.) and 
kept at this heat for six minutes. When properly prepared, the 
resultant, so-called " humanized milk," presents the albuminoids 
in a minutely coagulable and digestible form ; has an alkaline 
reaction ; contains the proper proportion of salts, milk sugar and 
fat, and has the appearance of human milk. 

Leeds gives the following analysis of this prepared milk : — 

Water, 86.2 per cent. 

Fat, 4.5 

Milk sugar, 7. " 

Albuminoids, 2. " 

Ash (salts), 0.3 " 

This corresponds very closely with his average analysis of 
human milk. 

In using this powder, too, one can readily return to a plain 
milk diet by gradually shortening the time of heating ; in other 
words, by slowly diminishing predigestion. 

Great and deserving stress has recently been placed upon a 
method of preparing, or rather preserving, cows' milk, known as 
"Sterilization." 

As milk exists in the healthy cow's udder it is aseptic, L e., 

* Measure provided with each can of powder. 



THE GENERAL MANAGEMENT OF CHILDREN, 



8 9 



free from any poisonous or dangerous ingredient, but during 
milking, and subsequent handling and transportation, particles 
of manure or various forms of dirt get into it and are apt to set 
up fermentation or other injurious change. To deprive these 
accidentally introduced organic impurities of their activity, or, 
in other words, to sterilize, it is necessary to subject the fluid to 
high heat under pressure. 

Several admirable implements have been devised for conduct- 



FlG. 




AUTHOR S STERILIZER. 



ing the process ; one of the most simple, made after a design of 
my own, is shown in the accompanying figure. 

This apparatus is made of tin, and consists of an oblong case 
provided with a well fitting cover, and having a movable per- 
forated false bottom (d), which stands a short distance above 
the true one and has attached a framework capable of holding 
ten, six-ounce, nursing bottles. On the outside of the case is a 
row of supports (b) for holding inverted bottles while drying, 
and at the proper distance below these a gradually inclining 
8 



90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

gutter (c) for carrying off the drip. A movable water bottle (a) 
is hung to the side ; in this each bottle of food may be heated at 
the time of administration. 

The bottles are made of flint glass and according to the design 
described on page 96, the graduated markings being especially 
convenient for measurement and rendering the use of a separate 
measuring glass unnecessary, a matter of no little moment, as 
every implement that comes in contact with the milk in sterili- 
zation must be kept chemically clean. Ten bottles are used, so 
that the whole supply of milk intended for a day's consumption 
can be prepared at once. Each bottle is provided with a per- 
forated rubber cork, which in turn is closed by a well-fitting glass 
stopper. 

Sterilization should be performed in the morning as soon as 
possible after the milk has been served The process is as 
follows : First, see that the ten bottles are perfectly clean and 
dry; pour into each six fluidounces (12 tablespoon fuls) of milk; 
insert the perforated rubber corks, without the glass stoppers, 
however; remove the false bottom and place the bottles in 
the frame ; pour into the case enough water to fill it to the 
height of about two inches ; replace the false bottom carrying 
the bottles; adjust lid, and put the whole on the kitchen range. 
Allow the water to boil and, by occasionally removing the lid, 
ascertain that the expansion that immediately precedes boiling 
has taken place in the milk, then press the glass stoppers into 
the perforated corks, and thus hermetically close each bottle. 
After this, keep the apparatus on the fire and the water boiling 
for twenty minutes. Finally, remove the false bottom with the 
bottles ; pour out the water, replace and carry the whole, covered 
with the lid, to the nursery. 

When the hour of feeding arrives, put one of the bottles into 
the attached water bath and heat it to the proper point for 
administration. The milk may, of course, be diluted with fil- 
tered water, or receive the additions ordinarily made to adapt it 
to children of different ages. The tip used — and a tube must 
not be employed even here — should be thoroughly cleaned and 



THE GENERAL MANAGEMENT OF CHILDREN. 9 1 

immersed for a few moments in boiling water before it is attached 
to the bottle. 

So soon as a bottle is emptied — and if the whole of its con- 
tents be not taken the remainder must be thrown away — it is 
washed in the ordinary manner with a solution of bicarbonate or 
salicylate of sodium (see p. 96) and placed in the rack (b) to 
drain and dry. 

Milk sterilized by the above process will remain sound for 
several days, according to some authorities as many as eighteen * 
when the heating is continued for thirty minutes. 

Sterilized milk is especially useful in travelling, when fresh 
milk cannot be obtained ; for use in cities during the heat of 
summer, when milk is most apt to undergo injurious changes ; 
for the feeding of delicate children, or for those suffering from 
disease of the stomach or intestinal canal. 

A very good process has been inaugurated by some dairymen, 
in which the milk is sterilized on the farm directly after coming 
from the cow, and transported to the consumer in the original 
bottles. This procedure cannot be too highly recommended, 
provided the care is taken to preserve perfect cleanliness on the 
part of the original handlers, and to see that the process of 
sterilization is thoroughly carried out. 

Sometimes milk, in every form and however carefully pre- 
pared, ferments soon after being swallowed and excites vomiting, 
or causes great flatulence and discomfort, while it affords little 
nourishment. With these cases the best plan is to withhold milk 
entirely for a time and try some other form of food. The fol- 
lowing are good substitutes: — 

Mellin's Food, gj. 

Hot water, f g iij. 

For each portion; to be given every two hours at the age of six weeks. 



* Since writing the above, this statement has been verified by my own 
experiments. 



92 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Veal broth (^ lb of meat to the pint), fgiss. 

Barley water, fgiss. 

For one portion. 

Whey, fgiss. 

Barley water, fgiss. 

Milk sugar, 3 ss. 

A teaspoonful of the juice of raw beef every two hours will 
usually be retained when everything else is rejected. 

Such foods are only to be used temporarily until the tendency 
to fermentation within the alimentary canal ceases ; then milk 
may be gradually and cautiously resumed. 

When infants approaching the end of the first year become 
affected with indigestion, it is often sufficient to reduce the 
strength and quantity of the food to a point compatible with 
digestive powers. For instance, at eight months the food may 
be reduced to that proper for a healthy child of six months, or 
even less. Here, too, predigestion of the food is very serviceable. 

If a few grains of extractum pancreatis be added to a gobletful 
of thick, well-boiled starch gruel, at a temperature of ioo° F., 
the gelatinous mucilage quickly grows thinner and soon is trans- 
formed into a 'fluid, the starch having been rendered soluble by 
the action of the pancreatin ; by still longer contact, the hy- 
drated starch is converted into dextrine and sugar. Advantage 
may be taken of this property to render the foods containing 
starch assimilable. Thus, to a mixture of barley jelly and milk, 



e. g. 



Barley jelly, ^ij. 

Milk sugar, ^j. 

Warm milk, f^y'n}. 

Add three grains of extractum pancreatis, and five grains of bicarbonate of 
sodium, and keep warm for half an hour before administering. 

The same process may be employed with food containing oat- 
meal, arrowroot or wheaten flour, with a view of converting the 
starchy ingredients into digestible elements without materially 
altering the taste. 



THE GENERAL MANAGEMENT OF CHILDREN. 93 

When the infant has arrived at an age to take meat broths, 
these too, when digestion is enfeebled, may be readily peptonized. 

Returning to the regimen of the healthy infant, it will be 
found that after the first year far less change is required in the 
food from month to month. 

Diet from the twelfth to the eighteenth month, five meals per 
day : — 

First meal, 7 a.m. — A slice of stale bread, broken and soaked 
in a breakfast-cup (eight fluidounces) of new milk. 

Second meal, 10 a.m. — A teacup of milk (six fluidounces) with 
a soda biscuit or thin slice of buttered bread. 

Third meal, 2 p.m. — A teacup of beef tea (six fluidounces) 
with a slice of bread. One good tablespoonful of rice-and-milk 
pudding. 

Fourth meal, 6 p.m. — Same as first. 

Fifth meal, 10 p.m. — One tablespoonful of Mellin's Food with 
a breakfast-cupful of milk. 

To alternate with this : — 

First meal, 7 a.m. — The yelk of an egg lightly boiled, with 
bread crumbs ; a teacupful of new milk. 

Second meal, 10 a.m. — A teacupful of milk with a thin slice 
of buttered bread. 

Third meal, 2 p.m. — A mashed, baked potato, moistened with 
four tablespoonfuls of beef tea; two good tablespoonfuls of junket. 

Fourth meal, 6 p.m. — A breakfast-cupful of new milk with a 
slice of bread broken up and soaked in it. 

Fifth meal, 10 p.m. — Same as second. 

The fifth meal is often unnecessary, and sleep should never be 
disturbed for it ; at the same time, should the child awake an 
hour or more before the first meal, he must break his fast upon 
a cup of warm milk, and not be allowed to go hungry until the 
set breakfast hour. 

Diet from eighteen months to the end of two and one-half 
years, four meals a day : — 

First meal, 7 a.m. — A breakfast-cupful of new milk ; the yelk 
of an egg lightly boiled ; two thin slices of bread and butter. 



94 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Second meal, n a.m. — A teacupful of milk with a soda biscuit. 

Third meal, 2 p.m. — A breakfast-cupful of beef tea, mutton or 
chicken broth ; a thin slice of stale bread ; a saucer of rice-and- 
milk pudding. 

Fourth meal, 6.30 p.m. — A breakfast-cupful of milk with bread 
and butter. 

On alternate days : — 

First meal, 7 a.m. — Two tablespoon fuls of thoroughly cooked 
oatmeal or wheaten grits with sugar and cream ; a teacupful of 
new milk. 

Second meal, 11 a.m. — A teacupful of milk with a slice of 
bread and butter. 

Third meal, 2 p.m. — One tablespoonful of underdone mutton 
pounded to a paste ; bread and butter, or mashed baked po- 
tato, moistened with good plain dish gravy ; a saucer of junket. 

Fourth meal, 6.30 p.m. — A breakfast-cupful of milk, a slice of 
soft milk toast, or a slice or two of bread and butter. 

When sickness supervenes, all that is ordinarily necessary is a 
reduction of the diet to plain milk, or milk with Mellin's Food. 

An important point, often neglected, is the matter of drink. 
Even the youngest infant requires water several times daily, and 
the demand increases with age. The water must be as pure as 
possible and should not be too cold. In the heat of summer, 
however, bits of ice and water moderately cooled by ice can be 
allowed without harm. 

The foregoing schedule must, of course, be regarded only as 
an average. Many children can bear nothing but milk food up 
to the age of two or even three years, and, provided enough be 
taken, no fear for their nutrition need be entertained. If a 
child be thriving on milk, he is never to be forced to take 
additional food merely because a certain age has been reached ; 
let the healthy appetite be the guide. 

A young mother, in her solicitude to do her best, often finds 
great difficulty in adhering to simple rules in the diet of her 
child. Mrs. A., who has had great experience with children, 
having had some herself, tells her that the child would thrive far 



THE GENERAL MANAGEMENT OF CHILDREN. 



95 



better if it ate such and such a thing, and did not keep to weak 
milk foods. Miss B. assures her that her cousin's last child grew 
much healthier after eating a chop with vegetables and pudding 
each day. Aunt C. comes with the announcement — which she 
breaks gently — that she knows the child is simply starving, and 
the ignorant nurse confirms the statement. 



Fig. 




GRADUATED NURSING BOTTLE. 



All their seemingly convincing theories are very upsetting to 
a mother who wants only to do what is right. She must bear in 
mind, however, that some children can eat anything and live ; 
but she does not know how much better, more robust, and 
disease-resisting they would be, did they adhere to a simple diet. 
Let her remember that the so-called " weak milk foods' ' contain 
those nourishing qualities to which nature, in her wisdom, has 



o6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

limited the child's powers of digestion. Therefore, young 
mothers, let well enough alone. 

d. Success in hand-feeding depends quite as much on the 
administration as upon the preparation of the food. 

From birth up to such time as broth, bread, and eggs are 
added to the diet, all the food should be taken from a bottle. 
Even after this, as the bottle is a comfort and insures slow feed- 
ing, it may be allowed for milk preparations, until the child, of 
his own accord, tires of it. The only feeding apparatus to be 
admitted to the nursery is the simple bottle and tip. The bottle 
represented in Figure 3 is made, by my suggestion, by Mr. J. 
J. Ottinger, of Philadelphia. Its interior surface presents no 
angles for the collection of milk ; it is easily cleaned, and the 
graduated scale is convenient for nursery use. 

All complicated arrangements of rubber and glass tubing are 
not only an abomination, but a fruitful source of sickness and 
death. Rather than use them, it is far better to feed the infant 
with a spoon. In England, a bottle with a long rubber tube is 
almost universally employed. Should this be abandoned and a 
simple bottle and a rubber tip used, the objections of some 
authors to bottle-feeding would vanish. 

The bottle shaped as above must be of transparent flint glass, 
so that the slightest foulness can be detected at a glance, and 
may vary in capacity from six to twelve fluidounces, according 
to the age of the child. Two should be on hand at a time, to 
be used alternately. Immediately after a meal the bottle must 
be thoroughly washed out with scalding water, filled with a 
solution of bicarbonate or salicylate of sodium — one 

Fig. 4. m J 

teaspoonful of either to a pint of water — and thus 
allowed to stand until next required ; then the soda 
solution being emptied, it must be thoroughly rinsed 
with cold water before receiving the food. The tips 
or nipples, of which there should also be two, must 
be composed of soft, flexible India-rubber, and a 
conical shape is to be preferred, as being more 
readily everted and cleaned; the opening at the point must be 




BOTTLE TIP. 



THE GENERAL MANAGEMENT OF CHILDREN. 97 

free, but not large enough to permit the milk to flow in a stream 
without suction. At the end of each feeding the nipple must be 
removed at once from the bottle, cleansed externally by rub- 
bing with a stiff brush wet with cold water, everted and treated 
in the same way, and then placed in cold water and allowed to 
stand in a cool place until again wanted. 

While taking these precautions for perfect cleanliness, the 
nurse must satisfy herself of their efficacy by smelling both the 
bottle and the tip just before they are used, to be sure of the 
absence of any sour odor. 

Next to cleanliness of the feeding apparatus, it is important to 
insist upon the separate preparation of each meal immediately 
before it is to be given. The practice of making, in the morning, 
the whole day's supply of food, though it saves trouble, is a most 
dangerous one. Changes almost invariably take place in the 
mixture, and by the close of the day it becomes unfit for con- 
sumption. 

When the graduated bottle is not at hand, a common glass 
graduate, marked for fluidrachms and ounces and holding a pint, 
should be provided for the nursery. Some moments before meal- 
time, so as to avoid hurry, measure the different fluid ingredients 
of the food in this, one after the other ; add the requisite quantity 
of milk sugar, and mix the whole thoroughly by stirring with a 
spoon, and pour into the feeding bottle. When the graduated 
bottle is employed, thorough shaking is sufficient. The food 
must now be heated to a temperature of about 95° F. This can 
be done by steeping the bottle in hot water, or by placing it in a 
water-bath over an alcohol lamp or gas jet. Finally, apply the 
tip and the meal is ready. 

When feeding, the child must occupy a half-reclining position 
in the nurse's lap. The bottle should be held by the nurse, at 
first horizontally, but gradually more and more tilted up as it is 
emptied, the object being to keep the neck always full and pre- 
vent the drawing in and swallowing of air. Ample time, say five, 
ten or fifteen minutes, according to the quantity of food, should 
be allowed for the meal. It is best to withdraw the bottle occa- 



98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

sionally for a brief rest, and after the meal is over, sucking from 
the empty bottle must not be allowed, even for a moment. 

e. For children residing in cities, an honest dairyman must be 
found, who will serve sound milk and cream from country cows 
once every day in winter, and twice during the day in the heat 
of summer. The milk of ordinary stock cows is more suitable 
than that from Alderney or Durham breed, as the latter is too 
rich and, therefore, more difficult to digest. The mixed milk of 
a good herd is to be preferred to that from a single animal. It 
is less likely to be affected by peculiarities of feeding, and less 
liable to variation from alterations in health or different stages of 
lactation. 

The care of the herd and of the milk is of great consequence. 
The cows should be healthy, and the milk of any animal that 
seems indisposed should not be mixed with that from perfectly 
healthy animals. The cows must not be fed upon swill or the 
refuse of breweries, glucose factories, or any other fermented food. 
They must not be allowed to drink stagnant water, and must not 
be heated or worried before being milked. The pasture must be 
free from noxious weeds, and the barn and yard must be kept 
clean. The udder should be washed, if dirty, before the milking. 
The milk must be at once thoroughly cooled. This is best accom- 
plished by placing the can in a tank of cold spring water, or in 
ice water, the water being the same depth as the milk in the can. 
It is well to keep the water in the tank flowing ; indeed, this is 
necessary unless ice water be used. The can should remain un- 
covered during the cooling and the milk should be gently stirred. 
The temperature should be reduced to 6o° F. within an hour, and 
the can must remain in the cold water until the time for deliver- 
ing. 

In summer, when ready for delivery, the top should be placed 
in position and a cloth wet in cold water spread over the can, or 
refrigerator cans may be used. At no season should the milk be 
frozen, and at the same time no buyer should receive milk having 
a temperature over 65 ° F. 

The milk and cream must be transported from the dairy in 



THE GENERAL MANAGEMENT OF CHILDREN. 99 

perfectly clean vessels. To insure this it is best to provide two 
sets of small cans ; one set to be thoroughly cleansed and aired 
while the other is taken away by the milkman to bring back the 
next supply. So soon as this arrives in the morning, or in the 
morning and evening in hot weather, the milk should be emptied 
into separate and absolutely clean earthenware or glass pitchers, 
and these put at once into a refrigerator reserved exclusively for 
them. This may stand in some convenient spot near the nursery, 
but not in it, and especially not in an adjoining bath room. With 
a good refrigerator there is no difficulty in keeping milk perfectly 
sweet for twenty-four hours in winter and for twelve hours in 
summer, except on intensely hot days ; then it may be necessary 
to scald, lightly boil or sterilize the whole of the supply when 
received, in order to prevent change. 

It is a well-known fact that milk is a fluid having active powers 
of absorption, and that it frequently acts as the medium of trans- 
mission of the contagion of such diseases as scarlatina, diphtheria 
and typhoid fever. Doctor V. C. Vaughan has also lately dis- 
covered in milk a special poison which he terms lyrotoxicon 
(cheese poison). 

The clinical elements of interest in these discoveries is the 
close analogy between the symptoms produced by the experi- 
mental use of tyrotoxicon and those observed in cholera infantum 
— an analogy suggestive of the possibility of the latter disease 
being chiefly due to poisoned milk. This causal relation is 
scarcely more than a theory, though certain well-known features 
of the disease seem to bear it out. Thus, the affection occurs at 
a season when decomposition of milk takes place most rapidly ; 
it occurs at places where absolutely fresh milk cannot be obtained ; 
it prevails among classes of people whose surroundings are most 
favorable to fermentative changes; it is most fatal at an age 
when there is the greatest dependence upon milk as a food, when 
the gastro-intestinal mucous membrane is most susceptible <to 
irritants, and when irritation and nervous fevers are most easily 
produced. 



IOO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Drs. Newton and Wallace, of the New Jersey State Board of 
Health, have reported a number of cases of poisoning by milk 
that occurred in different hotels at Long Branch. These ob- 
servers found that the affected milk was all obtained from one 
milkman, 'and that the cows furnishing it were milked at the 
unusual hours of midnight and noon. The noon milking was 
immediately placed in cans without being cooled, and "carted 
eight miles during the warmest part of the day in a very hot 
month.' ' It was this milk that produced the poisonous effects, 
the morning's milk being always good. No statement is made as 
to the health of the cows or the nature of the poison, but there is 
a probability of its having been tyrotoxicon, and of this material 
or its ferment having been generated by the careless collection 
and transportation of the milk, combined with the high atmos- 
pheric temperature. 

Childhood. — Children who have cut their milk teeth may be 
fed for a twelvemonth — namely, up to the age of three and a half 
years — in the following way : — 

First meal, 7 a. m. — One or two tumblerfuls of milk, a saucer 
of thoroughly cooked oatmeal or wheaten grits, and a slice of 
bread and butter. 

Second meal, 11 a. m. (if hungry). — A tumblerful of milk or 
a teacupful of beef tea with a biscuit. 

Third meal, 2 p. m. — A slice of underdone roast beef or mutton 
or a bit of roast chicken or turkey, minced as fine as possible ; a 
baked potato thoroughly mashed with a fork and moistened with 
gravy ; a slice of bread and butter ; a saucer of junket or rice- 
and-milk pudding. 

Fourth meal, 7 p. m. — A tumblerful of milk and one or two 
slices of well-moistened milk toast. 

From three and a half years up the child must take his meals 
at the table with his parents, or with some reliable attendant who 
will see that he eats leisurely. The diet, while plain, must be 
varied. The following list will give an idea of the food to be 
selected : — 



THE GENERAL MANAGEMENT OF CHILDREN. IOI 

BREAKFAST. 

EVERY DAY. ONE DISH ONLY EACH DAY. 

Milk. Fresh fish. Eggs, plain omelette. 

Porridge and cream. Eggs, lightly boiled. Chicken hash. 

Bread and butter. " poached. Stewed kidney. 

" scrambled. " liver. 

Sound fruits may be allowed before and after the meal, 
according to taste, as oranges, grapes without pulp (seeds not to 
be swallowed), peaches, thoroughly ripe pears, cantaloupes and 
strawberries. 

DINNER. 

EVERY DAY. TWO DISHES EACH DAY. 

Clear soup. Potatoes, baked. Hominy. 

Meat, roasted or broiled, " mashed. Macaroni, plain. 

and cut into small Spinach. Peas. 

pieces. Stewed celery. String-beans, young. 

Bread and butter. Cauliflower. Green corn, grated. 

Junket, rice-and-milk or other light pudding, and occasionally ice cream, 
may be allowed for dessert. 

SUPPER. 

EVERY DAY. 
Milk. 

Milk toast or bread and butter. 
Stewed fruit. 

Fried food, highly-seasoned or made-up dishes are to be ex- 
cluded, and no condiment but salt is to be used. 

Eating, however little, between meals, must be absolutely 
avoided. Keep a young child from knowing the taste of cakes 
or bonbons, or, having learned it, let him feel that they are as 
unattainable as the thousand other things beyond his reach, and 
he soon ceases to ask for them. Even a piece of bread between 
meals should be forbidden. His appetite then remains natural, 
and he will eat proper food at his regular meal hours. 

Filtered or spring water should be the only drink; tea, coffee, 
wine or beer being entirely forbidden. 

As to the quantity, a healthy child may be permitted to satisfy 
his appetite at each meal, under the one condition that he eats 
slowly and masticates thoroughly. 



102 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

In case of illness, the diet must be reduced in quantity and 
quality, according to the rules that are applicable to adults. 

2. Bathing. 

During the first two and a half years of life a child ought to 
be bathed once every day. The bath should be given at a regu- 
lar time, and it is best to select some hour in the early morn- 
ing, midway between two meals — ten o'clock, for instance. The 
tub should be placed near the fire or in a warm room in winter, 
and away from currents of air in summer. It should contain 
enough water to cover the child up to the neck when in a sitting 
posture, and the temperature must be about 95 ° F. Upon un- 
dressing the child, the first step is to wet his head J then he is 
to be plunged into the water and thoroughly washed with a soft 
rag or sponge, and pure, unscented castile soap. After remain- 
ing in the water from three to five minutes the surface must be 
well dried, and rubbed with a flannel cloth or soft towel ; then 
the body must be enveloped in a light blanket and the infant 
either returned to his crib to sleep, or kept in the lap for ten or 
fifteen minutes, until thoroughly warm and rested, and finally 
dressed. If there be repugnance to the bath, the tub may be 
covered over with a blanket, and the child being placed upon it, 
may be slowly lowered into the water without seeing anything to 
excite his fears. 

In very hot weather, in addition to the morning full bath, the 
body may be sponged twice daily, with water, at a temperature 
of 90 F. ; this, contrary to what might be expected, has a 
greater and more permanent cooling effect than bathing with 
cold water. 

After the third year, three baths a week are quite sufficient. 
An evening hour is now to be preferred, but the water must still 
be heated to 90 . 

About the tenth year cooler baths can be begun, from 72 to 
75 being the proper temperature. The cold sponge or cold 
plunge is not admissible as a daily routine until youth is well 
advanced. 



THE GENERAL MANAGEMENT OF CHILDREN. 103 

The hot bath — 95 to ioo° — is employed for various purposes, 
notably for a derivative action ; to cause diaphoresis, to relieve 
nervous irritability, and to promote sleep. Whether a full bath 
or merely a foot-bath be required, five minutes is a sufficient 
time for immersion \ then, with or without drying, according to 
the degree of sweating desirable, the whole body, or only the 
feet and legs in case of a foot-bath, must be enveloped in a 
blanket, and the child put to bed. To render these baths more 
stimulating, from a teaspoon ful to a tablespoon ful of mustard 
flour may be added, and the child held in the water until the 
arms of the nurse begin to tingle. 

It is important not to continue a hot bath too long, lest the 
primary stimulating effect be followed by depression. Cold 
baths, by shocking the system, first produce depression ; but this 
is temporary, and is followed by reaction, during which the 
skin grows red, and the pulse becomes fuller and stronger. They 
have, therefore a general stimulant and tonic action, promoting 
nutrition and giving tone to the body. On account of the 
shock, the extent of which depends directly upon the coldness 
of the water, these baths must be used with caution, and are not 
to be employed in very young or feeble subjects. 

When giving a cold bath, the child must be stripped in a 
warm room, and thoroughly rubbed with the palm of the hand 
until the whole body, especially the spinal region, is reddened ; 
he must then stand in a tub containing enough hot water to 
cover the feet, and be rapidly sponged with the cold water. The 
temperature of the latter must never be below 6o°, and the 
addition of half an ounce of sea-salt or a tablespoonful of con- 
centrated sea water to the gallon, renders it more stimulating 
and insures a complete reaction. After the sponging, the surface 
must be thoroughly and quickly dried with a soft towel and 
shampooed with the open hand until aglow. 

The cooled bath may be employed with advantage in ex- 
treme conditions of hyperpyrexia. The child is first immersed 
in water at 95 °, and this is gradually lowered to 70 by the 



104 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

addition of cold water, the process occupying from fifteen to 
thirty minutes. 

Various medicated baths are employed. Of these the most 
useful are : — 

The Mustard Bath. 

Take from two drachms to one ounce of powdered mustard ; hot water, two 
to four gallons. 

Derivative in form of foot-bath ; stimulant as general bath. 

Salt- Water Bath. 

Take two ounces of rock salt, or Ditman's sea-salt, or concentrated sea-water 
(best) ; water (hot or cold, according to season), four gallons. 

General bath, to be used every morning in chronic tuberculosis, scrofula, 
rickets and general debility. Bath to be followed by thorough rubbing of the 
surface, especially over the spine. 

Bran Bath. 

Take one pint of bran, tie up in a muslin bag, place in a quart of water, 
boil for an hour, squeeze bag thoroughly into the water; add to four gallons 
of warm water. 

Useful in eczema and skin diseases. 

Nitro- Muriatic Acid Bath. 

Take muriatic acid, one fluidrachm ; nitric acid, two fluidrachms; warm 
water, four gallons. 

Serviceable in hepatic sluggishness. Make bath in a wooden tub. May be 
employed as a foot or general bath. 

Mercurial Bath. 

K- Hydrarg. Chlorid. Corros., gr. v. 

Alcohol, f^ij. 

Aq. Dest., f 5jj. 

M. 

S. — Add to four gallons of water. Employed in syphilitic skin diseases. 

Soda Bath. 

Take half an ounce of bicarbonate of sodium ; warm water, four gallons. 

Used in skin affections. 

Astringent Bath. 

Take one pound of oak bark, one quart of water, boil for half an hour, 
strain and add to four gallons of warm water. 



THE GENERAL MANAGEMENT OF CHILDREN. T05 

3. Clothing. 

Infants and young children have little power of resisting 
cold, and on this account require warm clothing. Too much 
cannot be said in condemnation of the fashion of allowing 
children to go, even while in the house, with bare legs and 
knees. 

Every child is supplied with a certain amount of nerve force 
to be daily expended in the maintenance of the different func- 
tions of the body — respiration, circulation, digestion, calorifi- 
cation, etc. If an excessive proportion of this force be con- 
sumed in keeping up the heat of the body, as is the case when 
so much is left bare, the other functions, especially the digestive, 
must suffer in consequence. 

During the oppressive heat of summer, the legs may be left 
uncovered ; but throughout the rest of the year, the whole body 
must be encased in woolen underclothing. The thickness of 
this must vary, of course, with the season. Providing this be 
done, the outer clothing may be left to the taste of the mother ; 
but all garments should fit loosely, that the functions of the dif- 
ferent viscera may not be impeded by pressure. 

The best pattern of a winter night-dress is a long, plain slip, 
with a drawing-string at the bottom, to prevent exposure of the 
feet and limbs, should the child kick off the bed-covering. This 
should be made of flannel, or, the more easily washed, Canton 
flannel. In summer, a loose muslin one may be put on, without 
the drawing-string. A flannel under-vest should always be worn 
at night, light gauze in summer and heavier wool in winter ; care 
must be taken, however, to have one for night alone, discarding 
that worn in the daytime. 

In infants under a year old, a broad flannel abdominal band- 
age, extending from the hips well up to the thorax, or, better still, 
a knitted worsted band shaped to fit the form, is very useful in 
keeping the abdominal organs warm, aiding digestion, and pre- 
venting pain. 

All clothing should be changed sufficiently frequently to insure 
cleanliness. 
9 



106 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Shoes must be large, well shaped and made of soft leather, 
with pliable soles, so as to allow the feet to grow freely. 

When dressing a child for exercise in the open air in cold 
weather, the outer clothing must not be put on until just before 
leaving the house, and removed immediately on return. 

It is important to protect the head from cold in winter by a 
close-fitting, thick cap ; and from the direct rays of the sun in 
summer by a broad-brimmed, light straw hat. 

Rubber shoes are necessary in wet weather to keep the feet 
warm and dry while walking out of doors. 

4. Sleep. 

For some time after birth, infants spend the intervals between 
being fed, washed and dressed in sleep, and thus pass fully 
eighteen out of the twenty-four hours. As age advances, the 
amount of sleep required becomes less, until at two years thir- 
teen hours, and at three years eleven hours, are enough. Any 
marked diminution in the length of sleep or decided restlessness 
indicates disease, and demands attention from the physician. 
This matter, though, is, perhaps, more a question of training 
than any other item of nursery regimen, and many a mother, 
by want of judicious firmness, has rendered the early years of 
her child's life not only a burden to himself, but an annoyance 
to the entire household. 

One cannot too soon begin to form the good habit of regu- 
larity in sleeping hours, and so far as circumstances will admit, 
the following rules may be enforced : — 

From birth to the end of the sixth or eighth month, the infant 
must sleep from 11 p.m. to 5 a.m., and as many hours during 
the day as nature demands and the exigencies of feeding, wash- 
ing and dressing will permit. 

From eight months to the end of two and a half years, a 
morning nap should be taken, from 12 m. to 1.30 or 2 p.m., the 
child being undressed and put to bed. The night's rest must 
begin at 7 p.m. If a late meal be required, the child can be 
taken up at about ten o'clock, but if past the age for this, he may 



THE GENERAL MANAGEMENT OF CHILDREN. 107 

sleep undisturbed until he wakes of his own accord, some time 
between 6 and 8 a.m. 

From two and a half to four years, an hour's sleep may or 
may not be taken in the morning, according to the dispo- 
sition of the subject ; but in every case the bed must be occu- 
pied from 7.30 p.m. to six or seven o'clock on the following 
morning. 

After the fourth year, few children will sleep in the daytime ; 
they are ready for bed by 8 p.m , and should be allowed to 
sleep for ten hours or more. 

A later retiring hour than 9 p.m. ought not to be encouraged 
until after the twelfth or fifteenth year. 

When feasible, different rooms should be used for the day 
nursery and the sleeping apartment. The latter should be large, 
airy, well ventilated, so situated as to be exposed for a certain 
period each day to the direct rays of the sun, and provided 
with an open fire-place — for wood, preferably — which serves for 
both heating and ventilating. It should contain a bed for the 
nurse and a crib for the child, and be without curtains, heavy 
hangings or superfluous furniture. A stationary washstand drain- 
ing into a sewer is not to be permitted in the room, neither 
should it communicate with a bath-room. Soiled diapers or 
chamber utensils are to be removed at once, no matter what 
the time of night. The day nursery should have large windows, 
protected by blinds, and a southwestern exposure ; all other 
requisites, with the exception of beds, are the same as in the 
sleeping room. It is very convenient to have the two chambers 
adjoining, but capable of entire separation by a door, so that 
one may be thoroughly aired without chilling the other. This 
arrangement, too, renders it practicable, by standing the door 
open and raising the windows in the day nursery, to keep the 
dormitory cool in hot weather without exposing the child to 
currents of air. 

If an apartment has to be occupied during both the day and 
night, it must be vacated for half an hour or more in the even- 
ing and well aired before the child is put back to bed. 



Io8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The temperature of the rooms must be as uniform as possible, 
the proper degree of heat being from 64° to 68° F. 

The crib should have high sides, to prevent the child from 
falling out and injuring himself, and should be provided with 
springs and a soft hair mattress, protected by a gum cloth, 
placed under a double sheet. The bedclothes must be light in 
weight, while varying in warmth according to the weather; it is 
just as important to insist upon cleanliness here as in the clothing 
of the body. 

5. Exercise. 

A certain amount of muscular exercise is necessary for de- 
velopment and for the proper performance of the digestive 
functions. Infants, before they are able to stand, will use their 
muscles sufficiently if, when loosely clad, they are placed upon 
their backs in a bed and allowed to kick and turn about at 
pleasure. After the age of nine or ten months, a healthy child 
will begin to creep ; at the end of a year, he will make efforts 
at standing, and from four to eight months later, will be able to 
walk by himself; children however, present great differences in 
this respect, and a delay of a few months must not be considered 
as abnormal. So soon as efforts at creeping are made, there 
need be no fear that insufficient exercise will be taken ; the care 
should be rather to prevent over-fatigue. 

Fresh air and sun-light are as necessary as muscular exercise. 
The child must be taken out of doors every day, weather per- 
mitting, after arriving at the proper age : this is four months for 
children born in the early fall and winter, and one month for 
those born in summer. 

In cool weather, babies who are unable to walk should be 
taken out in a coach, or in the nurse's arms, for an hour in the 
morning and half an hour in the afternoon, while the sun is 
shining. In summer, they may pass the greater part of the 
waking hours in the open air, provided they be well protected 
from the direct rays of the sun. 

Children old enough to walk may spend a longer time in the 



THE GENERAL MANAGEMENT OF CHILDREN. I09 

air in winter, and may be out all day in summer. But until the 
fourth year, it is better to let them play about at will than take 
a long set walk. 

Until well advanced in childhood, the house is the safest place 
in damp and rainy weather, when there is a strong east or north 
wind blowing, and when the thermometer stands below 15 . 

Management of Weak and Immature Infants. — When pre- 
mature expulsion of the foetus cannot be checked, children are 
born in a condition of feebleness requiring particular care. Such 
children are under weight, breathe and eat imperfectly ; have ill- 
formed organs and badly performed functions ; their skin is soft 
and delicate, bright red in color, and so transparent that the 
superficial blood-vessels can often be seen, and their cry is feeble. 
Their muscles are inert, they hardly seem to contract, and the 
movements of the limbs are rare and without vigor. The infant, 
plunged in a sort of stupor, has not even strength enough to suck, 
the muscles of the cheeks and of the tongue and palate being 
apparently too weak to perform this act, and deglutition itself is 
often slow, — a grave symptom, since the regular accomplishment 
of this function alone renders life possible. 

The employment of artificial heat and a well-regulated alimenta- 
tion are the methods of combating this condition. Warmth and 
even temperature of the surrounding air are most important. The 
old method of accomplishing this was to envelop the infant's body 
and limbs, under the ordinary clothing, with a layer of cotton 
wadding, and place a fold of the same around the head. Two 
or three bottles filled with hot water were placed under the blan- 
kets of the bed, and renewed from time to time as they became 
cold. An effort was made to maintain the temperature of the 
chamber at 77 Fahr. All changes of clothing were made before 
a brisk fire, and two or three times every day massage or friction, 
either dry or with various stimulating embrocations, was practiced 
to strengthen the circulation. As an improvement upon this 
crude and very unsuccessful method, M. Tarnier has devised an 
apparatus called a " hatching-cradle/ ' 

It consists of a box made of wood, sixty-five centimetres long 



no 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



by fifty high and thirty-six wide, with sides twenty-five milli- 
metres thick. The inside of the box is divided by a partial par- 
tition into two parts; this partition, which is horizontal, is 
placed about fifteen centimetres from the bottom. The lower 
story is intended for hot-water bottles. 

The cut shows the apparatus. 

There are two doors ; one is a sliding door on the side of the 
box to push to either side for the purpose of introducing the hot- 
water bottles ; the other is at one of the ends (at T in this figure); 

Fig. 5- 




tarnier's "hatching-cradle." 

it does not completely close the orifice, but allows air to enter. 
The upper part, for the baby, contains the bedding, and is covered 
with a glass top at V ; it should close tightly and be held by two 
screws at BB. At A is an outlet for the air, to which a small 
ventilator can be attached. In the opening between the two 
chambers a wet sponge is placed to keep the air slightly moist, 
and here also a thermometer is placed to mark the temperature. 
The heat is supplied by earthenware jugs at M ; they contain a 
pint of water each ; four or five are required to keep the tempera- 
ture at the proper point, — 87-90 F. The chamber must be 



THE GENERAL MANAGEMENT OF CHILDREN. Ill 

heated to this degree before the infant can be placed in it, and 
every one and a half or two hours one of the water bottles must 
be changed in order to maintain a constant temperature. The 
air passes in by the door, T, is heated by the bottles, and passing 
by the sponge, E, escapes at A ; the movements of the small ven- 
tilator in the latter position is the index that the air is circulating. 
The infant must be dressed in swaddling clothes, as it has been 
observed that the temperature is always two or three degrees 
higher under the clothing than in the chamber itself. Every hour 
or two, according to the case, the little patient should be taken 
out to receive food and have its napkins changed. The shorter 
time occupied in these processes the better. 

Auvard has suggested an improvement in Tarnier's hatching 
cradle. In his instrument a cylindrical reservoir of metal takes 
the place of the hot-water jars in the lower compartment of the 
couveuse. This reservoir is filled by means of a metallic funnel 
at one end of the box and communicating with the cylinder 
through a metallic tube. 

The overflow of the cylinder is provided for by a curved me- 
tallic tube at the lower part of the cylinder, beneath the inlet 
through which the reservoir is filled. 

The air enters by a register on one side of the couveuse instead 
of at the end, as in Tarnier's apparatus. The other portions of 
the apparatus are the same as Tarnier's. 

The metallic cylinder is capable of holding ten litres of liquid 
(a litre is a little over a quart). To start the apparatus, about 
five litres of boiling water should be poured in, after which three 
litres may be poured in every hour. When jten litres are con- 
tained in the cylinder, the overflow-pipe carries off the excess. 
Auvard suggests having two vessels, capable of holding three 
litres each, keeping one under the escape-pipe and the other over 
the fire, reheating the water in the vessel filled by the escape- 
pipe and having it in readiness for the next changes. The two 
vessels may be thus used alternately, and but little time consumed 
in the heating of the apparatus as compared with that required 
in the use of Tarnier's invention. 



1 12 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



To empty the cylinder, a rubber tube is attached to the escape- 
pipe, by which it is made to act as a siphon — a small quantity 
of water poured into the cylinder through the funnel being suffi- 
cient to start the liquid. 

The length of time the child remains in a couveuse will vary 
from fifteen days to three weeks, a month, or even more. It 
should not be removed permanently until it has acquired suffi- 
cient vigor to live in the ordinary atmosphere of the apartment. 
To accustom the child to this atmosphere, it should, as it grows 
stronger, be removed for an hour at a time from the couveuse 
during the warmest part of the day. 

It is best to continue the use of the apparatus at night for some 
time after the child becomes accustomed by day to removal from 
the couveuse, for the danger of chilling from changes in the 
atmosphere is greater at night. 

Auvard recommends the use of the couveuse in all cases where 
the vitality of the child is enfeebled either by external causes, as 
cold, or internal causes, as prematurely congenital feebleness, 
cyanosis, or " blue disease," wasting, or other general maladies 
enfeebling to the newborn. 

The excellent results obtained by these cradles is shown by the 
following statistics obtained from the Maternite, in Paris : — 



WEIGHT OF CHILD. 


NO. OF INFANTS. 


NO. THAT LIVED. 


NO. THAT DIED. 


1000-1500 grammes. 
1 501 -2000 
2001-2500 " 


40 

131 
112 


12 

96 
IOI 


28, or 70 per cent. 
35, or 26.7 " 
it, or 9.8 " 



Before the introduction of the machine, infants died at the 
rate of 66 per cent.; since, the average proportion is 36.6 per 
cent. 

The heated cradle has also been used with success in the treat- 
ment of sclerema, oedema and cyanosis attacking the newly 
born. From the very first day an attempt must be made to put 



THE GENERAL MANAGEMENT OF CHILDREN. 113 

these feeble infants to the breast ; and if they be too weak to 
suck, the milk may be squeezed into the mouth, or first into a 
warm spoon and then given to the child. The mother's or 
nurse's milk, without dilution or addition, is the best food, 
though if this cannot be obtained asses' milk may be used. This 
must be mixed with equal quantities of warmed sugar and water 
— 3 parts to 100. When the cows' milk is employed, the mixture 
should be one part to three of the same sugared water. M. 
Tarnier recommends the cows' milk to be prepared thus : The 
mixture of milk and sweetened water is placed in an air-tight 
pot, and this is placed in boiling water for half an hour. It is 
given to the child from a small spoon. When the infant is very 
small, six to eight grammes (f3ij) are enough for a meal ; larger 
babies require from ten to fifteen grammes (f 3 i iss— f 3 iiiss) . There 
should be at least twelve meals every twenty-four hours. 

It often happens that the babe will drink badly and throw up 
half the liquid given. Under this deficient feeding the little 
sufferer gets rapidly worse, loses weight, and frequently has 
diarrhoea. In these cases "gavage" is resorted to. The appa- 
ratus is quite simple, being nothing more than a urethral 
catheter of red rubber (Nos. 14-16 French), at the open end 
of which a small glass funnel is adjusted. The infant upon 
whom gavage is to be practiced is placed on the knee, with its 
head slightly raised ; the catheter, being wetted, is introduced 
as far as the base of the tongue, whence, by the instinctive efforts 
at deglutition, it is carried as far down as the oesophagus and 
into the stomach. The liquid food is next poured into the 
funnel, and by its weight soon finds its way into the stomach. 
After a few seconds the catheter must be removed, and here is 
the great point in the operation : it must be removed with a 
rapid motion and at once, for if it be withdrawn slowly all the 
food introduced will be vomited. 

The number and quantity of meals thus given must vary with 

the age and strength of the infant. As a rule, eight grammes 

(f3ii) of food every hour will suffice when the subject is small, 

but there must be an increase as circumstances require. Mother's 

10 



114 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

milk is the best in gavage, but other foods may be used if it be 
impossible to obtain it. 

Should the gavage be too copious, the infant gains rapidly in 
weight and size. This increase, however, is due to oedema, and 
quickly disappears when a proper quantity of food is adminis- 
tered. When excessive feeding is continued, indigestion soon 
sets in, and the patient dies of gastritis or enteritis. As soon as 
the child gains strength this mode of feeding may be alternated 
with nursing, and gradually breast-feeding may be entirely sub- 
stituted for it. Nevertheless, the least digestive disturbance in- 
dicates the necessity of a return to gavage. 

Even when the child is old enough to nurse, should it be 
weak, it is useful, besides regularly giving the breast, to resort to 
gavage three or four times a day. This is what M. Tarnier calls 
gavage de renforf, as it keeps up the strength of the infant so that 
it can take the breast and digest well. 

The absence of the sensation of hunger and of the necessary 
strength to suck are not contra-indications to this mode of feed- 
ing ; and by it, together with the use of hatching machines, the 
actual period of vitality has approached the legal period, which 
in French law is six months of intra-uterine life. 

Lavage. — Epstein, of Prague, has practiced lavage of the 
stomach in nursing children with good results. The apparatus 
employed consists of an elastic tube joined to a small glass tube, 
to the other extremity of which another piece of elastic tubing 
with a wide opening is adapted. Lavage may be practiced a few 
days after birth without the least danger to the infant. The 
instrument is inserted while the child is in the dorsal decubitus 
position, the trunk and arms being enveloped in napkins. The 
child's mouth is opened by exerting a slight pressure upon the 
chin, while the larynx is slightly pressed inward by the index 
finger of the right hand. The tube having been previously 
dipped in warm water, it is held as a pen, and the smaller 
extremity slowly introduced, advancing by the simple, repeated 
act of deglutition. The contact of the tube with the stomach 
causes contractions of the walls, thereby expelling a quantity of 



THE GENERAL MANAGEMENT OF CHILDREN. 115 

liquid through the tube, the broad end of which is depressed 
somewhat until the stomach is empty. The author employs dis- 
tilled water with a little hydrocarbonate of soda, using from 
twenty to twenty-five cubic centimeters of the liquid for each 
lavage. The funnel-shaped end of the tube is raised to pour 
in the water and lowered to expel it. The washing may be 
repeated two or three times in succession until the liquid returns 
nearly clear. 

Lavage is indicated : i. In cases of repeated vomiting. 2. In 
cases where there is present an affection of the mouth which is 
capable of extending to the stomach. 3. In cases of eclampsia 
caused by indigestible substances. 4. In cases of poisoning. 

After the lavage the child should remain perfectly quiet for 
fifteen or twenty minutes before nursing. 



PART III.— MASSAGE IN PEDIATRICS. 



Systematic manipulation is of great value both as a means of 
preserving health and as a scientific method of treating certain 
diseases in children. 

Mere rubbing or friction of the surface cannot be included 
under massage in its literal sense, still, it is a useful form of 
manipulation, and needs no special instruction, being possible 
to any intelligent, soft-handed mother or nurse. 

Massage, on the contrary, is an art, and, like every other art, 
requires study and patient preparation for its successful practice. 
It is a powerful remedy too, and, like other agents of its class, 
as potent for evil as for good in unskilled hands. Therefore, to 
insure good results, a trained masseuse is necessary — and she 
must act under the direction of the physician. 

Massage includes several processes of manipulation. Those 
given by Murrell, from whose excellent little work* I have taken 
much of the description of the different " movements/' are effleur- 
age, petrissage, friction and tapotement. 

Effleurage is a stroking movement made with the palm of 
the hand passing with more or less force over the surface of the 
body centripetally. The movements are made to follow as 
nearly as possible the direction of the muscle fibres, and for 
deep-seated tissues the knuckles can be used instead of the palm. 
This method is of minor value in itself but of great use when 
combined, as is the rule, with the procedures to be described. 

Petrissage consists essentially in picking up a portion of 
muscle or other tissue with both hands, or the fingers of one 
hand, and subjecting it to firm pressure, at the same time rolling 

*" Massage as a Mode of Treatment." W. Murrell. 

Il6 



MASSAGE IN PEDIATRICS. 117 

it between the fingers and the subjacent tissues. The hands 
must move simultaneously and in opposite directions, the skin 
must move with the hands to avoid giving pain, and the thumb 
and fingers must be kept wide apart in order to grasp a bulk of 
tissue, a whole muscle belly, for instance. The manipulation 
must be uniform, in a direction from the extremities toward the 
centre of the body, bearing in mind the arrangement of groups 
of superficial muscles and keeping well in the interstitia. 

Friction, or massage a frictions, is performed with the tips of 
the fingers. It is a pressure movement rather than a rubbing. 
It is always associated with efHeurage and, to be of any use, must 
be performed quickly and readily. 

Tapotement is a percussion which may be made with the tips 
of the fingers, their palmar surfaces, the palm of the hand, the 
back of the half-closed hand, the ulnar or radial border of the 
hand, or with the hand flexed so as to contain, when brought in 
contact with the surface of the body, a cushion of air. 

The hand of the masseuse must be perfectly clean and soft, and 
the finger nails short and smooth. The length and frequency of 
the sittings must vary with the individual case. Murrell is in 
favor of short and frequent seances, and also recommends d?y 
massage, that is, without the use of oil, liniments or ointments ; 
vaseline especially is to be avoided. 

Our knowledge of the physiological action of massage is based 
upon experimental research and clinical experience. Experi- 
ments were made by Dr. Gopadze (quoted by Murrell) upon four 
medical students, who were kept in hospital and subjected to 
systematic manipulations for twenty minutes or more daily. The 
seance began with efiieurage, followed by petrissage, friction and 
tapotement, and ending with a second efHeurage. The results 
were increased appetite and a notable gain in body weight. The 
axillary temperature fell, never more than .5°, for about thirty 
minutes after each massage ; then it rose steadily, and an hour 
later was generally a degree higher than at the commencement 
of the operation. The respiratory movements were uniformly 
increased in frequency, depth and fulness. The pulse varied 



Il8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

with the kind of "movement" used — light surface effleurage 
increased its frequency, while petrissage made it slower. 

Zabludowski, experimenting on himself and two servants for 
eighteen days, noted increased bodily and mental vigor and 
improved appetite and sleep. 

Clinical experience shows that massage increases the activity of 
the circulation, reddens the skin and elevates the tempera- 
ture in the part manipulated. It also increases the electrical 
contractility of muscular tissue, and stimulates the flow of lymph 
in the lymphatic vessels. Muscular stiffness and fatigue are 
relieved, nervous irritability is calmed, and restless and wakeful 
patients are soothed by it into refreshing sleep. 

With these facts at hand, it is not difficult to see what a useful 
therapeutic agency we possess in skillfully employed massage. By 
its application we have the power to prevent the atrophy of mus- 
cles and to augment muscle tone, to build up such tissues as fat and 
blood, to improve nerve tone both directly by producing a better 
blood supply and indirectly by relieving irritability and giving 
rest and sleep, and, finally, to hasten the absorption of waste tissue 
and of morbid effusions. At the same time it must always be 
remembered that massage is a powerful remedy. A short seance 
with gentle movements may do good in infantile palsy, for ex- 
ample, but it does not follow that by doubling the time or force 
twice as much benefit will be derived. In fact, the reverse of 
the proposition is true ; short, gentle massage maintains the size 
and tone of the muscles, while long, forcible manipulation 
causes them to atrophy quickly. The same truth runs through 
the whole question and must be observed. 

Before entering upon the therapeutic application of massage 
proper, it will be well to revert to the process of simple rubbing, 
already mentioned. This is of much value as a general hygienic 
measure. Each day, after the bath, the skin having been thor- 
oughly dried by a soft, warm towel, the whole surface should be 
gently rubbed with the palm of the hand, the process occupying 
about five minutes. This increases the capillary circulation, 
encourages thorough reaction, aids nutrition and adds vigor to 



MASSAGE IN PEDIATRICS. I ig 

the frame. Weakly children especially thrive under it. In older 
children, friction with a soft towel may be substituted for hand- 
rubbing, but this change should not be made before the fifth or 
sixth year. 

Sometimes it is well to rub certain portions of the body more 
thoroughly than others. Thus in rickets the spine should receive 
especial attention, in indigestion and constipation the abdomen, 
in weak ankles the feet and legs, etc.; though even in these cases 
the general surface must receive a share. 

Massage may be employed with advantage in the following 
diseases of childhood : — 

(a) Chronic gastro-intestinal catarrh. In this condition the 
skin is harsh, and often so dry that a shower of epidermic scales 
falls on the removal of the underclothing, the muscle tone is 
faulty, general nutrition is impaired, and there is a determination 
of blood from the surface toward the mucous membranes. To 
get the skin active, and in this way balance the circulation, is an 
important step in the reestablishment of normal digestion, secre- 
tion and excretion, the essentials of perfect nutrition. To accom- 
plish this, a full, warm bath is administered every evening, just 
before bedtime, the patient remaining in the water for five min- 
utes. Then the surface is thoroughly dried and half an ounce 
of olive oil is gently rubbed into the skin, the child enveloped 
in a light blanket and put to bed. After a little time diaphoresis 
begins. So soon as the sweating is free the skin is again dried 
and the night-dress put on in preparation for sleep. Next 
morning, at some convenient time after breakfast, the child is sub- 
jected to twenty minutes' massage (petrissage with effleurage). 
The inunctions are continued until the skin becomes soft and 
active, and massage is employed daily until there is a decided 
improvement in the amount of flesh and general strength, a 
period generally of two or three weeks. Afterwards "move- 
ments" every third day will be sufficient to complete the 
cure. 

In these cases massage not only aids the baths and inunctions 
in their general action, but directly and powerfully increases 



120 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

nutrition and muscle tone, and materially hastens an otherwise 
slow process of recovery. 

(£) Constipation. Manipulation is a very efficient remedy in 
habitual constipation, and there are many cases that can be cured 
by it, combined with a properly regulated diet, without the use 
of drugs. Petrissage of the colon is the best method, instructions 
being given to follow the natural course of the faeces through 
this portion of the gut ; thus, beginning in the right iliac region 
to proceed upward to the right hypochondrium, to cross over to 
the left hypochondrium and then downward to the left iliac 
region. In this way the ascending transverse and descending 
colon are manipulated in order. 

Five or ten minutes every morning, or every morning and 
evening in obstinate cases, constitute the proper duration and 
frequency of the applications. The pressure must be gentle, as 
delicate tissues are being dealt with. 

In this condition I have not found the dry method so efficient 
as the combination of massage with the inunction of warm olive 
oil or a weak ammonia liniment. The addition of aloes to the 
liniment, a plan recommended by some authors, has never been 
necessary in my experience. 

Sometimes tapotement with the flat hand, the hand partly 
closed forming a cushion, or with the margin of the hand, is 
necessary, but the course of the colon must always be followed. 
The therapeutic action of this mode of treatment is, undoubtedly, 
threefold: it increases the intestinal and other secretions; it 
increases the peristaltic action of the intestinal muscular fibres, 
and it mechanically forces accumulated faecal matter toward the 
rectum. 

(7) Colic. Every experienced mother knows how often flatus, 
the cause of colicky pain, is expelled from the stomach or 
intestines by gently rubbing the abdomen with the hand. Any 
approach to scientific manipulation is much more efficient, and 
two or three minutes' effleurage may be resorted to, as the 
urgency of the symptoms requires, with the most satisfactory 
effect. In this connection it must be remembered, also, that 



MASSAGE IN PEDIATRICS. 121 

rubbing of the feet to increase the circulation is an important 
aid in relieving colic. 

(y) General debility and anaemia. These conditions are much 
benefited by short, frequently repeated courses of massage. In 
the convalescence from many diseases, both acute and chronic, 
in which these states exist, manipulation improves general nutri- 
tion, and strength is rapidly gained. 

(e) Infantile paralysis. Here massage of the paralyzed muscles 
brings more blood into them and maintains their nutrition until, 
in favorable cases, new cells in the cord take on the function of 
those which have been destroyed. 

In essential paralysis the affected members are always cold, and 
the muscles contract feebly, if at all, under the influence of elec- 
tricity. By systematic massage — petrissage combined with efHeur- 
age and both performed centripetally — an improvement takes place 
with more or less rapidity. The first indication of this is an increase 
in the temperature of the parts, continuing for several hours after 
the rubbing. Then the electrical contractility of the muscles 
begins to return, and they respond to a current that at the com- 
mencement is entirely inoperative. 

In recent cases the sittings should be of short duration and 
frequently repeated, five to ten minutes, three or four times daily. 
As improvement advances, the frequency may be reduced, and 
in chronic cases twice a day will be sufficient at any time. 

Electricity is of great aid in the treatment, but it does not 
take the place of massage, for while it causes contraction and 
congestion of the muscles and hyperaemia of the skin, it does 
not have the same power of arresting rapid wasting. The con- 
stant current is to be employed. In the commencement the 
current must be mild, so as not to produce pain or emotional 
excitement, and often it is well to apply empty sponges for 
several sittings, to accustom the little patient to the novelty of 
the procedure without producing any sensation. The treatment 
may be begun about three weeks after the onset of the paralysis, 
earlier applications being attended by the risk of increasing 
spinal congestion. 



122 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Well wetted, large sponges should be used. The positive pole 
is kept stationary and placed close to the sacrum or lower part of 
the back when the legs are to be galvanized and to the back of 
the neck in case of the arms. The negative pole is slowly moved 
up and down over the surface of the affected limb, thus making 
and breaking the circuit gradually and without pain. The muscles 
that do not contract to Faradism are the ones to be influenced 
by galvanism ; in other parts hyperaemia of the muscles and skin 
only is required. 

Three or four electrical sittings a week are sufficient. They 
should be short at first, ten to fifteen minutes, and gradually in- 
creased in duration and force as tone and contractility return, 
care being taken never to over-fatigue the muscles. 

(/) Chorea. So far as this branch of the management of 
chorea is concerned, it requires to be aided by proper diet and 
rest in bed. On the onset of an acute attack the patient is put 
to bed, given a full supply of good food and allowed to rest for 
two days without massage. Should the choreic movements be 
very violent, the sides of the bed are padded to prevent the 
child bruising himself, or, if too violent for this, to give security, 
he is slung in a hammock. 

At- the end of this time the regular treatment is initiated. The 
plan, a slight modification of that recommended by Goodhart, 
is as follows : — 

The child — at seven years of age, for example — has, at 5.30 
a. m. , half a pint of warm milk ; 7 a. m. , half a pint of milk and 
three slices of bread and butter (each slice an ounce in weight); 
9.45 a. m., a teaspoonful of Merck's dry malt in a little milk; 
10 a. m., massage for fifteen minutes, followed by half a pint of 
warm milk; 12.30 p. m., a teacupful of rice pudding, half a 
pint of milk, green vegetables and mashed potatoes; 4.15 p. m., 
half a pint of warm milk, three slices of bread and butter and a 
lightly boiled egg; 7 p. m., malt as before; 7.30 p. m., massage 
for fifteen minutes, followed by half a pint of milk. At the end 
of ten days or a fortnight, the bread and butter is increased to 
four slices at 7 a. m. and 4.15 p. m.; a lean broiled chop is 



MASSAGE IN PEDIATRICS. 123 

added to the mid-day meal, and an extra pint of milk is dis- 
tributed over the twenty-four hours. After two or three weeks 
the patient may be allowed to sit up in bed, well supported by 
pillows, and may have a few toys to play with. It is a golden 
rule, however, never to hurry a patient with chorea out of bed. 
The muscular strength is more quickly recovered while at perfect 
rest, and too early exertion often causes a relapse. While carry- 
ing out this plan Goodhart employs no medicines, but in my 
experience recovery has been more rapid under the conjoint use 
of Fowler's solution, administered in daily increasing doses. 

(g) Other nervous diseases in which massage is employed 
with success are pseudohypertrophic paralysis ; facial paralysis ; 
neurasthenia and spinal irritability occurring in girls about the 
approach of puberty, and that ill-defined and painful condition 
so often encountered in young subjects and known as "growing 
pains. " 

(A) Pleuritic effusions (serous); fibroid pleurisy ; enlarged lym- 
phatic glands, and stiffened rheumatic joints are all benefited 
by rubbing. In these special instances the manipulations are 
generally combined with the use of embrocations, though the 
curative effects cannot be attributed to the latter alone. 

In concluding the subject of massage in childhood, it is a point 
of importance to mention that those cases in which the manipu- 
lation is immediately followed by a sensation of comfort or by 
refreshing sleep are most benefited by it. On the contrary, those 
cases that are stimulated, derive little benefit, and perhaps posi- 
tive injury from rubbing. This I have especially noted in cases 
of general debility and anaemia, and my own experience has 
been confirmed by a number of practical observers in whose judg- 
ment I have the greatest confidence. 



PART IV.— DISEASES OF THE DIGESTIVE 

ORGANS. 



CHAPTER I. 
AFFECTIONS OF THE MOUTH AND THROAT. 



i. CATARRHAL STOMATITIS. 

The Anatomical Lesion in this affection consists of a simple 
hyperaemia of the mucous membrane of the mouth, with its 
attendant redness, swelling, and altered secretion. This hyper- 
semia varies both in extent and degree. Sometimes it is limited 
to small, circumscribed points of the membrane, at others it 
extends over large patches, or involves the entire surface. In 
the latter cases it is most intense, the mucous glands of the lips 
and cheeks participate, becoming enlarged and prominent, and 
occasionally small herpetic patches appear. 

The disease may be primary or secondary. 

Etiology. — The causes of primary stomatitis are the ingestion 
of food or drinks which are acrid and irritating or too hot ; the 
eruption of teeth; the presence of decaying teeth; want of 
cleanliness of the mouth ; exposure to cold and wet ; and the 
use of certain drugs, as mercury, iodine, antimony and arsenic. 
The secondary form occurs during the course of measles, scarla- 
tina, typhoid fever, and disordered conditions of the stomach, 
particularly those attended by acid eructations. Catarrhal stoma- 
titis is also met with in the earlier stages of more serious diseases 
of the mouth. 

While not limited to any special age, the disease occurs most 

124 



AFFECTIONS OF THE MOUTH AND THROAT. 1 25 

commonly during dentition, since at this period several of its 
causes are apt to be simultaneously operative. 

Symptoms. — These are mainly local. The lips are unnaturally 
full and red, and the skin at the angles of the mouth and on the 
chin may be excoriated by the dribbling saliva. The oral mucous 
membrane presents either a punctated, a patchy, or a diffuse 
redness. It is moderately swollen, and hot and tender to the 
touch. At first the mouth is dry, but soon the salivary flow is 
increased, the secretion becoming acid in reaction, and sometimes 
viscid and flocculent. The mucous glands of the cheeks and 
lips may project as yellowish-white or transparent nodules, yield- 
ing a drop of mucus on pressure. Infrequently, too, isolated 
collections of small vesicles develop and then quickly dry up, 
leaving scales behind them. The tongue is either red and smooth, 
with enlarged and reddened fungiform papillae, or covered with 
a white frosting, through which the papillae project in scarlet 
points. The last condition is most frequently seen when the 
stomatitis is secondary to gastric catarrh. The acts of sucking 
and eating are painful, and resistance is offered to inspection of 
the mouth. Cold drinks are craved. 

Restlessness, irritability, slight heat of skin, anorexia — depend- 
ing chiefly upon the local tenderness — and constipation, are the 
general symptoms of primary catarrhal stomatitis. In the second- 
ary variety the general symptoms depend upon and vary with, 
the originating disease ; the local features, however, remain the 
same. 

The course of the disease depends upon the cause and the 
treatment adopted, though it is usually acute, rarely lasting longer 
than a week. 

Treatment. — After attending to the removal of the exciting 
cause, if this be possible, the diet must be regulated. To suck- 
lings, the breast or the carefully prepared bottle alone should be 
allowed, and milk guarded by lime-water must constitute the 
food of older children. If the act of sucking be so painful as to 
cause the infant to refuse the breast or bottle, it is necessary to 
give food, temporarily, from a spoon or glass. 



126 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The mouth should be thoroughly washed, at intervals of an 
hour, while the patient is awake, with a solution of borax or 
chlorate of potassium in rose water (gr. x to fSj). After taking 
food, particularly, the mouth ought to be cleansed with cool 
water, and the lotion used. A little mass of absorbent cotton 
twisted around the end of a probe, or a soft rag folded around 
the index finger, are the best vehicles for carrying the lotion. 

Regular evacuation of the bowels must be secured by saline 
laxatives. If the skin be hot and dry, liquor potassii citratis, in 
doses of a fluidrachm every two or three hours, for a child one 
year old, is indicated. When the tongue is heavily frosted, and 
the stomach disordered, recovery may be much hastened by 
using the following prescription: — 

R . Sodii Bicarbonatis, , gr. xxiv. 

Pulv. Pepsime (Fairchild's), gr. xij. 

Pulv. Aromatici, gr. iij. 

M. et ft. chart. No. xij. 
S. — One powder four times daily, administered in milk or syrup, for 
a child between seven and twelve months old. 



2. APHTHOUS STOMATITIS. 

This is a much more common disease than uncomplicated 
catarrhal stomatitis, and is most frequently met with in children 
between the ages of six and fifteen months. 

The Anatomical Lesions are hyperaemia of the mucous mem- 
brane of the mouth, and the formation of aphtha or small, super- 
ficial, yellowish-white ulcers. 

Etiology. — Any condition which reduces the general strength 
and interferes with nutrition may exert a predisposing influence. 
For instance, over-crowding; residence -in damp, ill-ventilated 
houses or rooms ; insufficient food and clothing ; chronic dis- 
eases, especially of the digestive tract ; scrofula and the tuber- 
culous tendency. 

The exciting agencies are, want of proper attention to the 
cleanliness of the mouth ; foul nursing bottles; the admin istra- 



AFFECTIONS OF THE MOUTH AND THROAT. 1 27 

tion of sour milk, or an excess of farinaceous food, and dentition. 
After the completion of the first dentition, an indulgence in 
pastry or candy is often followed by an attack of aphthae, and 
certain children always suffer after eating some particular article 
of food, as honey, walnuts, or salted fish. All of these causes 
are active in the production of a catarrhal state of the stomach, 
which invariably precedes and attends the disease under consid- 
eration. 

The disease is not contagious, though at times a sufficient num- 
ber of cases occur simultaneously to constitute an epidemic. 

Symptoms. — For twenty- four hours prior to the appearance of 
aphthae, there is fretfulness, increased thirst and poor appetite. 
Next, the mouth becomes hot, and a few hours later the ulcers 
appear, without any previous vesication.* The lips, swollen and 
vividly red, are held somewhat apart, and clear saliva drops from 
the mouth, excoriating the skin of the lower lip and chin. The 
oral mucous membrane is red, swollen, and hot, and presents 
the characteristic ulcers. These are usually discrete, and make 
their appearance first on the inside of the lower lip and the edges 
of the tongue, though they may, subsequently, extend to the 
cheeks, gums, soft palate, and even the tonsils. Their number 
varies from one to twenty, and their size, from that of a pin's 
point to a split pea. The ulcers, oval, round, or, more rarely, 
linear in shape, are slightly elevated above the surrounding sur- 
face, have deeply reddened edges and whitish or yellowish-white 
floors. They are excessively sensitive, and thus mechanically 
interfere with sucking, chewing, speaking, or other movement 
of the mouth. The edges of the tongue are clean and red, while 
its dorsum is covered with a thick, white coating. 

Together with these local symptoms, there is restlessness, 
increased pulse rate, elevated surface temperature, dryness of the 
skin, thirst, anorexia, nausea with frequent eructations of acid 
liquid and occasional vomiting, and either constipation or di- 



* For confirmation of this statement, see Vogel, " Ziemssen's Cyclopaedia," 
Vol. vi, p. 779. 



128 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

arrhoea. The loss of appetite is due both to the painful condi- 
tion of the mouth and to the disordered state of the stomach. 

When all the ulcers appear simultaneously, the disease runs its 
course in from four to seven days. The fibro-cellular exudation 
covering their floors then disappears, leaving the mucous mem- 
brane beneath intact but intensely red, though occasionally 
shallow, clean ulcers are left, which quickly heal. At the same 
time the local and constitutional symptoms rapidly subside. If, 
on the contrary, the ulcers develop in successive crops, as is some- 
times the case, the duration may be prolonged for a fortnight or 
more. 

There is another form of aphthous stomatitis, termed confluent, 
in which the aphthae are very numerous, and tend to run together, 
forming large, irregular ulcers. The symptoms are proportion- 
ately severe. It occurs secondarily to grave constitutional dis- 
eases — namely, measles, variola, scarlet fever, diphtheria, typhoid 
fever, pneumonia and whooping cough. 

The Diagnosis of the ordinary, discrete form is unattended 
with difficulty. Thrush bears the closest superficial resemblance ; 
but in this disease the creamy-white spots are slightly raised above 
the surface, being deposits upon the mucous membrane. There 
are no ulcerations, the color of the free membrane is rather pur- 
plish than scarlet, and finally the thrush fungus is discoverable by 
the microscope. The graver, confluent form is distinguished from 
ulcerative stomatitis, by the absence of fetor, and by the different 
seat and appearance of the lesions. The ulcers in the latter dis- 
ease always begin at the margins of the gums, extend rapidly, and 
present grayish floors. 

Aphthae is usually a mild disorder, recovery taking place quickly 
and without difficulty. The confluent form, besides running a 
longer course, is more difficult to cure, on account of the general 
debility induced by the associated disease. 

Treatment. — Since some disturbance of digestion is con- 
stantly at the bottom of the local trouble, attention to the feeding 
apparatus and to the diet is of great importance. Absolute clean- 
liness of both bottles and tips must be insisted upon, and if a com- 



AFFECTIONS OF THE MOUTH AND THROAT. 129 

plicated, patent arrangement of rubber and glass tubing has been 
used with the bottle, it must be at once discarded and a simple 
rubber tip substituted. Regular hours for meals — the frequency 
varying with the age of the child — are as essential as the selection 
of suitable food and its administration in proper quantities. 

A child of six months should be fed every three hours, between 
6 o'clock in the morning and 9 o'clock in the evening. A 
mixture such as the following — 

Sound Milk, f g iv. 

Cream, f 3|j. 

Lime-water, f^ij- 

Sugar of Milk, one teaspoonful (gr. xl) ; 

may be made immediately before the time of feeding ; poured 
into an absolutely clean bottle, to which a clean tip is fitted, 
and the whole placed in a water-bath and heated to a tempera- 
ture of about ioo° F. This preparation is easily digested, con- 
tains enough lime-water to prevent rapid and firm clotting of 
the milk, and is not so great in quantity as to over-distend the 
delicate stomach and cause vomiting. 

Children of two years of age and over should be placed on a 
simple diet. A breakfast, luncheon and supper of stale bread 
and milk guarded by lime-water (one part to three) and a mid- 
day dinner of broth and well-boiled rice. 

The disease usually makes its appearance too long after the 
causative error of diet, to be stayed by the administration of an 
emetic. If, however, an overloaded stomach be indicated by 
fever, restlessness, and epigastric pain and distention, a dose of 
the wine or syrup of ipecacuanha* should be given. If the 
bowels be constipated a gentle laxative is required. Probably 
the best is calomel ; for a child from six to twelve months old a 
powder containing half a grain of the mercurial and five grains 
of sugar may be placed dry upon the tongue in the evening, to be 
followed next morning by a small teaspoonful of magnesia in 

* For a child of one year old the emetic dose of wine of ipecacuanha, is 
fifteen drops; of the syrup, half a teaspoonful, repeated if necessary. 
II 



130 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

milk or lemonade. If, on the contrary, there be diarrhoea, the 
bowels should be first cleared of irritating materials by a tea- 
spoonful of castor oil, into which five drops of paregoric have 
been dropped, and the following prescription given : — 

R . Sodii Bicarbonatis, gr. xxiv. 

Syr. Rhei Aromatici, 

Syrupi, aa f^ss. 

Aq. Men thee Piperita, q. s. ad f ^ iij. 

M. 

S. — A teaspoonful every three hours. 

The fever, when very moderate in degree, requires only a 
plentiful supply of cool water to drink, and a hot mustard bath 
in the evening. The strength of the latter should be one tea- 
spoonful of strong mustard to as much water as will cover the 
child's legs and hips when in a sitting posture. The duration 
of the bath should be from five to ten minutes. If the skin be 
quite hot and dry, a saline diaphoretic is necessary. The best 
is liquor potassii citratis, in doses of one teaspoonful every two 
hours. Sometimes it is well to add one-quarter of a drop of 
tincture of aconite to each dose of the potash solution. 

Locally, the best results will be obtained by lightly touching 
each ulcer with a point of lunar caustic. The pain incident to 
the application maybe prevented by the previous application of 
a 4 per cent, solution of cocaine. In ordinary cases one such 
application suffices, in severe, it is necessary to repeat it daily for 
a week or more. In addition the mouth must be washed thor- 
oughly and frequently, particularly after food is taken, with cool 
water, or with a solution of chlorate of potassium, as : — 

R . Potassii Chloratis, gr. xx. 

Vini Opii, TT\v. 

Glycerinae, fgj. 

Aquae Rosae, q. s. ad f Jj. 

M. 

After the fever has subsided, a digestant will be required for a 
few days. Thus, half a teaspoonful of wine of pepsin three 
times daily may be ordered ; or, if there be acidity with a coated 



AFFECTIONS OF THE MOUTH AND THROAT. 131 

tongue, the powder recommended, under the same circum- 
stances, in catarrhal stomatitis. 

The local treatment must be persevered in, until the ulcers 
have healed and the mucous membrane has returned to its normal 
condition. 



3. ULCERATIVE STOMATITIS.' 

This affection of the mouth is quite common in childhood. 
It is usually seen in children between three and eight years of age ; 
is never met with before the commencement of dentition, and is 
not contagious though it sometimes occurs in almost epidemic 
profusion. 

The Anatomical Lesions consist of parenchymatous inflam- 
mation of the gums, and often of the tongue and cheeks, with 
ulcerative destruction of the mucous membrane. Microscopical 
examination of the floors of the ulcers, reveals pus corpuscles, 
isolated blood corpuscles, and granulated cells, imbedded in an 
amorphous, finely granular mass which is filled with bacteria and 
micrococci. There is no trace of pseudo-membrane. 

Etiology. — As the disease is not contagious there is probably 
no specific epidemic influence in its causation. When groups of 
cases, large enough to be classified as epidemics, do occur, they 
are generally limited to single houses or institutions, and may 
be traced to bad hygienic surroundings affecting alike all the 
inmates. Insufficient or bad food and residence in unhealthy, 
cold, damp, ill-ventilated houses constitute one set of causes. 

Again, ulcerative stomatitis is very apt to follow in the wake of 
typhoid fever, scarlatina, measles, variola and dysentery, and 
since each of these primary diseases usually occurs as an epidemic, 
a similar tendency in the sequelae is readily explained. 

A certain amount of reduction of the constitutional vigor 
seems to be an essential precedent to the development of the 
disease. Sickly, rickety and scrofulous children are susceptible 
subjects, and when the gums are loose, soft and hyperaemic they 
are more readily affected than when firm and closely applied 



132 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

around the teeth. I have, however, seen it occur in the most 
healthy children. For instance, I lately saw it developed in two 
most robust children of 4 and 7 years, who had returned to the 
city after a summer in the mountains, during which there had not 
been a single day of illness, and, on the whole, two more robust 
specimens of healthy childhood could not well be found. This 
attack cou]d, most probably, be attributed to the opening of a 
sewer within a block of their home. 

The presence of decaying teeth, want of cleanliness of the 
mouth, and the careless administration of such medicines as mer- 
cury, lead and phosphorus, are exciting causes. 

Symptoms. — At first there is a sense of heat and pain in the 
mouth, and the breath grows offensive in odor. Next the gingi- 
val mucous membrane, immediately about and between the teeth, 
becomes red and swollen. The swelling rapidly increases, the 
points of the gum between the teeth standing out like flasks, and 
the whole margin becoming so soft and tender that it bleeds upon 
the lightest touch. In the course of twenty-four hours the edge 
of the gum, where it touches the teeth, changes from a bright red 
to a yellow or yellowish-gray color, and softens, breaking down 
into ulcers. 

Ulceration generally commences on the external surface of 
the lower gum, and in the beginning appears as a more or less 
extended, narrow and indented gray band, following the line of 
the teeth. Later it may appear on the outer surface of the 
upper gum ; on the internal surface of both the lower and upper 
gums ; on the edges of the tongue, at points where the organ 
presses against the teeth ; and finally on the cheeks. In the 
latter position it often happens that the ulceration corresponds 
exactly with that of one or both gingival borders, forming a single 
or double strip running parallel with the jaws. 

The ulcers are depressed, have a ragged, dirty gray or brownish 
floor, and intensely red, swollen edges. The mucous membrane 
not involved shows the characteristics of catarrhal stomatitis. 

When the disease is fully developed, the lips are tumid and red. 
They are held apart, and a stream of yellowish, sometimes bloody, 



AFFECTIONS OF THE MOUTH AND THROAT. 1 33 

always ill-smelling, acid and viscid saliva, constantly drips away, 
excoriating the skin over which it flows. If the mouth be kept 
closed, as it sometimes is, half an ounce or more of this fetid 
fluid gushes out whenever the lips are parted in speaking or in 
taking food. The submaxillary glands and the lymph glands of 
the neck are moderately enlarged, and there is often cedema of 
the face, limited or general, according to the extent of the 
ulceration. 

The mouth is the seat of constant burning and pain; is hot 
and tender to the touch, and chewing causes great suffering. 
Between and upon the teeth there is a deposit of yellow unctuous 
material. The tongue, in addition to presenting the marginal 
ulcers, is swollen and heavily coated with a dirty, yellowish-white 
fur. The speech is thick ; the breath has a characteristic heavy 
odor; there is loss of appetite, due principally to the pain pro- 
duced by chewing and the contact of food with the ulcerated 
mucous membrane ; thirst is moderately increased ; and the 
bowels are normal, or inclined to constipation. The little suf- 
ferer is restless and sleeps badly. The pulse is feeble, and there 
are other evidences of general debility, but there is little febrile 
reaction, the temperature, even in well marked cases, rarely 
reaching a higher marking than 99. 5 F. in the evening. 

In severe and protracted attacks, the ulcers increase in breadth 
and depth, become covered with a gray or brownish pulp, and 
the teeth, deprived of the support of the gum, grow loose and are 
easily removed from the alveoli. Sometimes the periosteum of 
the jaw is destroyed, and more or less extensive necrosis results. 
Exceptionally, in very weak and badly nourished children, the 
stomatitis runs into actual gangrene or noma. 

The symptoms, ordinarily, reach their height in from two to 
four days, and, under proper treatment, disappear in as many 
more, the ulcers cleaning off and healing without cicatrization. 
Severe or badly managed cases go from bad to worse for a time, 
and rarely recover under three or four weeks, during which the 
suffering is extreme. Those involving necrosis of the jaw, and 
those terminating in noma, run a still more protracted course. 



134 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Diagnosis. — The appearances of the gums before ulceration, 
the position in which this process begins, the character of the 
individual ulcers, and the odor of the breath, furnish a train of 
symptoms distinguishing ulcerative stomatitis from any other 
affection of the mouth. 

The Prognosis, in the vast majority of instances, is most favor- 
able. When necrosis of the jaw occurs the duration is greatly 
prolonged, but ultimate recovery is the rule. Intercurrent noma, 
on the contrary, often leads to the death of the child, and under 
the best of circumstances leaves its traces in permanent deformity 
of the face. 

Treatment. — The first step is to improve the sanitary sur- 
roundings of the patient, or, if this be impossible, to remove him 
to healthy quarters. The importance of cleanliness, fresh air, 
and sunlight, are not to be lightly estimated. 

The diet should be liquid, but nutritious. Apart from the fact 
that solid food will be refused on account of the pain caused 
by mastication, milk and animal broths are better suited to the 
somewhat enfeebled digestive powers, and should be relied upon 
entirely. Cool water ought to be allowed in sufficient quantities 
to satisfy the thirst. 

Of drugs, chlorate of potassium is the most important, since it 
ranks almost as a specific for this disease. It may be given alone, 
simply dissolved in water, or combined with dilute muriatic acid, 
as in this prescription : — 

& . Potassii Chloratis, gr. xlviij. 

Acidi Muriatici dil., f ^j. 

Syrupi, „ . . . . f% ss. 

Aquae, q. s. ad . . fgiij. 

M. 
S. — One teaspoonful, diluted, every two hours, for a child three years 
old. 

In this combination the chlorate of potassium, being eliminated 
by the salivary glands, constantly comes in contact with, and acts 
as an alterative upon, the ulcers. The muriatic acid aids digestion, 
and acts as a tonic. If a more decided tonic effect be required, 



AFFECTIONS OF THE MOUTH AND THROAT. 1 35 

one-quarter to one-half of a grain of sulphate of quinia may be 
added to each dose. 

Chlorate of potassium, too, constitutes the main element of 
the local treatment. Its action is somewhat improved by the 
addition of carbolic acid, as in the following wash : — 

R . Potassii Chloratis, gr. lxxx. 

Acidi Carbolici, gr. ij. 

Glycerine, f^j. 

Aquee, q. s. ad . . f ^ viij. 

M. 

A bit of absorbent cotton saturated with this wash should be 
thoroughly applied to all the ulcers at least once in every hour • 
or, at the same intervals, the child may take a quantity into the 
mouth, move the cheeks and tongue in such a way as to bring it 
in contact with the whole mucous surface, and then expel it. 
Should there be much pain, a four per cent, solution of cocaine 
may be applied to the ulcerated surfaces two or three times daily. 
I have also had good results from salicylate of sodium applied as 
a wash at intervals of two hours. 

After the ulcers have healed, the specific treatment may be 
discontinued, and the patient placed upon a simple tonic, as fer- 
rated elixir of cinchona, in doses of half a fluidrachm three times 
daily, until the health is perfectly restored. 

As additions to this treatment, iron and stimulants will be 
required in severe and protracted cases. The tincture of the 
chloride is the best form of iron. It should be given in doses of 
three drops (rryss) every two hours for a child three years old, 
and may be combined very well with the mixture of potash, acid 
and quinine (pp. 134-5). The best stimulant is whiskey, in 
doses of one-half to one teaspoonful, in milk or water, every 
three or four hours. Indolent ulcers may be stimulated to heal 
by touching them lightly with a solid stick of nitrate of silver, 
the parts being first anaesthetized by cocaine. Loosened teeth 
must always be allowed to remain in position, as they often 
become firm again after the termination of the disease. 

When necrosis occurs, no change is necessary in the general 



136 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

plan of treatment. Especial attention, however, must be paid 
to the cleanliness of the mouth, and poultices of flaxseed meal 
should be kept constantly applied to the cheek of the affected 
side. Surgical interference may become necessary. 



4. GANGRENOUS STOMATITIS— NOMA. 

This affection consists of a rapid gangrenous destruction of 
the cheek and adjacent parts, occasionally beginning on the lips, 
but usually near one corner of the mouth. It is generally asym- 
metrical, the left cheek being attacked in the majority of instances, 
but sometimes both cheeks are simultaneously involved. 

Etiology. — Noma is, fortunately, an uncommon disease. 
Sucklings seem to be exempt from it, and most of the cases occur 
between the ages of two and twelve years. Girls are more liable 
to be attacked than boys. It is always of secondary origin, fol- 
lowing severe maladies, such as measles, typhoid fever, gastro- 
intestinal catarrh, ulcerative stomatitis, scarlet fever, smallpox, 
broncho-pneumonia, tuberculosis, protracted intermittent fever 
and whooping cough. This order also represents the etiological 
activity of the diseases mentioned. These, then, may be looked 
upon as predisposing causes, but despite the presence of any one 
of them, noma only occurs in those children who have been pre- 
viously weak, ill housed and ill-nourished. 

There is no evidence to show that it is contagious, though it 
sometimes occurs as an endemic in overcrowded hospital wards 
and children's homes. These endemics may be explained in the 
same way as similar outbreaks of ulcerative stomatitis. 

Symptoms. — During convalescence from measles, or other of 
the diseases mentioned, a nodule, from a quarter to half an inch 
in diameter, appears spontaneously upon the child's cheek, in the 
neighborhood of the corner of the mouth. This can be easily 
detected from the outside, but it is best felt by opening the mouth 
and grasping the cheek between the thumb and forefinger. It is 
extremely hard, and very sensitive, especially at the periphery. 



AFFECTIONS OF THE MOUTH AND THROAT. 137 

If the case be seen during the first few hours, the mucous mem- 
brane over the mass will be observed to be converted into a flat, 
ichorous bulla. Usually, however, this membrane is found hang- 
ing in ragged shreds from a black, gangrenous base. The skin 
over the induration is pale or mottled with, purple spots, tense, and 
shiny as if oiled. 

After twenty- four hours, the investing integument becomes 
bluish, the epidermis scales off, and a black eschar forms. Tliis 
has a tendency to shrink, and in so doing, leaves a linear 
depression with ichor, which separates it from the healthy skin. 
Notwithstanding this line of demarcation, the tissue destruction 
rapidly extends, both in superficial area and depth. Soon the 
cheek is perforated, and a dirty, stinking, ichorous saliva, filled 
with shreds of broken-down tissue, flows out beside the eschar 
and over the cheek. At the same time the lips, chin, and unin- 
volved portions of the cheek become oedematous, the skin being 
tight and glistening, and the adjacent cervical glands enlarged. 

At the very outset there are few constitutional symptoms. The 
child complains of little or no pain, persists in his amusements, 
has a good appetite, a temperature but slightly above the normal, 
and a pulse but moderately increased in frequency. As the eschar 
forms, the scene changes, symptoms of constitutional depression 
setting in. The face is pale and expressionless on the affected 
side, the skin cool and dry, the pulse feeble and frequent — some- 
times counting 120 or 140 beats per minute — and there is oedema 
of the feet. The mind is apathetic, no complaints of pain are 
made, and at most a sense of discomfort is indicated by constant 
whimpering. The mouth is held partly open, the breath is fetid, 
the teeth and tongue are covered with sordes, and there is an 
abundant flow of bloody or dark-colored saliva. Severe hemor- 
rhage never occurs, as the blood-vessels are closed at an early 
stage. The appetite is often retained, the thirst is intense, and 
the bowels are usually relaxed. In spite of the food taken, the 
strength rapidly declines, sometimes, though, it is wonderfully 
retained, the patient being able to sit up, and even leave his bed, 
until a few hours prior to death. 
12 



I38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The air of the sick-room has a characteristic gangrenous odor. 

Perforation of the cheek occurs about the third day of the 
disease, and many cases die at this time. Others linger until 
the end of the first or second week. Under these circumstances 
the gangrene invades the lips as far as the median line, the corre- 
sponding ala of the nose, and the cheek as far as the lower eye- 
lids, the tragus, and the inferior border of the lower jaw. 
Extending inward, the gums and periosteum of the jaws are 
destroyed ; the bone becomes necrotic, and the teeth so loose 
that they can be readily pushed out by the finger, together with 
pieces of the alveoli. Finally the cheek is cast off in large, black 
sloughs, leaving huge openings, with black, ragged, and indurated 
edges, through which the blackened and necrosed bones and 
loosened teeth can be seen. The child's face is then unrecogni- 
zable ; the symptoms of constitutional depression are greatly 
intensified ; there is delirium, profuse diarrhoea, purulent and 
even gangrenous infiltration of the lungs, and occasionally, also, 
gangrene of the genitalia, in females. Death is the only result 
to be expected. 

Exceptional cases do recover. In these, the gangrenous edges 
become clean and covered with granulations, the necrosed bone 
is thrown off, and after months, cicatrization takes place, with 
great disfigurement. 

Pathology and Morbid Anatomy. — The fact that noma 
makes its appearance uniformly at one point, on the cheek, and 
is unilateral, suggests a localized, causative lesion. The most 
natural theory, that of embolism of a large arterial branch, due 
to weakness of the cardiac muscle or increased coagulability of 
the blood — effects of the primary disease — is untenable, because, 
with the given conditions, emboli ought, at least occasionally, to 
be found in other positions, which does not happen. It is neces- 
sary to look rather to the nerves ; namely, the trifacial, the facial, 
or the vasomotors. That the gangrene is due to a lesion of one 
of these, seems to be borne out by experiments. Thus, Magendie 
found that division of the trifacial in dogs caused destruction of 
the corresponding eyeball, and half of the tongue became dry, 



AFFECTIONS OF THE MOUTH AND THROAT. 1 39 

brown and fissured, the gums spongy and hemorrhagic, and the 
teeth loose. " In animals tenacious of life, the batrachians, for 
example, the soft portions of the face are cast off in shreds, just 
as in spontaneous gangrene. After three or four weeks only one- 
half of the face remains.' ' * 

The body of a child dead from noma has a gangrenous odor 
and decomposes quickly ; the skin is shriveled, and the face and 
the feet are oedematous. The gangrenous parts are converted 
into a blackish-brown mass, and the maxillary bones are naked, 
brownish in color and brittle. The nerves, when examined 
microscopically, are yellowish in color but unaltered in structure, 
and the blood vessels are thickened and filled with thrombi. In 
the uninvolved parts of the cheek there is a dense exudation, 
while the palate, tongue and tonsils are swollen and covered with 
black scales and crusts. The lungs are the seat of hemorrhagic 
infarctions, lobular or metastatic lobar pneumonia, and some- 
times gangrene. The intestines are catarrhal. Evidences of the 
primary disease may also be present ; for example, the lesions of 
typhoid fever or dysentery. Noma of the genitalia, though 
rare, is occasionally encountered. I have seen several cases 
within the last three years. The local appearances and the clini- 
cal history as to causation and so on, correspond with what has 
already been stated. The possibility of such an occurrence 
should be borne in mind as a matter of interest. 

Diagnosis. — Noma is readily distinguished from other oral 
affections by its course, its peculiar and almost uniformly identi- 
cal seat and its well marked local features. 

Ulcerative stomatitis is the only other of the class at all likely 
to be confounded with it. This always begins with ulceration 
of the gingival margin, and when the cheek becomes involved, 
the ulcers situated there are linear in shape and have a grayish 
floor. There is no sloughing or gangrene of the mucous mem- 
brane. The cheek never presents a circumscribed induration, 
being at most simply oedematous. The skin shows no tension, 

* Vogel, Ziemssen's Cyclopaedia, Vol. vi, p. 812. 



140 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

unctuous appearance or discoloration, and perforation of the soft 
parts never occurs. The breath is fetid but not gangrenous ; 
salivation is less, and the saliva, though sometimes bloody, is not 
mixed with shreds of gangrenous tissue. The course is much 
less rapid, and the ulcers, while they extend in area, retain the 
same appearances throughout. Finally, the general symptoms 
are distinctive, the results of treatment are most satisfactory, and 
a fatal termination is extremely uncommon. 

Malignant pustule closely resembles noma. The former, how- 
ever, always begins on the exterior, involving the epidermis first 
and extending through the successive layers of skin to the deep 
structures. 

The Prognosis is most unfavorable. Vogel sets the mortality 
at 80 to 90 per cent.,* and out of one hundred and two cases 
that came under the observation of Steiner,f only four recovered. 
Death may occur at any time between the third and fourteenth 
day ; a rapid course, however, is very much more frequent than 
the reverse. Even when recovery does take place, the patient is 
permanently disfigured by scars, or crippled by the development 
of ectropion, or of restricted movement of the jaw, in conse- 
quence of cicatricial contraction, or by the loss of teeth and por- 
tions of the maxillary bones. Such cases also drag through a 
very protracted convalescence. 

Treatment is most unsatisfactory. Something can be done 
in the way of prophylaxis, by a proper management of the known 
predisposing diseases. Secure sound hygiene in the sick-room ; 
give good nourishment, and avoid the abuse of mercurials and 
debilitating treatment generally. 

If, notwithstanding these precautions, noma appears, it is of 
the first consequence to maintain the strength by the use of con- 
centrated liquid food, tonics and stimulants. When perforation 
of the cheek takes place, the act of swallowing is mechanically 
interfered with. It is necessary then to resort to nutritious 



* Ziemssen's Cyclopaedia, Vol. vi, p. 814. 
f Diseases of Children, p. 218. 



AFFECTIONS OF THE MOUTH AND THROAT. 141 

enemata, suppositories of quinia, and even the rectal administra- 
tion of stimulants. 

The room in which the treatment is conducted must be large, 
airy, and so situated as to be exposed, for a part of the day, at 
least, to the sun's rays. In summer the windows should be kept 
constantly open, and in winter they must be raised for at least 
fifteen minutes several times daily, the patient being warmly 
covered in the meantime. The air of the chamber must also be 
kept as pure as possible by the use of disinfectants. For this 
purpose cloths saturated with a solution of chlorinated soda or 
with Piatt's Chlorides, may be hung about the bed. 

Early cauterization with the hot iron, with strong sulphuric or 
muriatic acid, or the solid stick of nitrate of silver, is recom- 
mended. All sloughs must be removed by scissors. The gan- 
grenous spot should be frequently bathed with a strong solution 
of chlorate or permanganate of potassium, carbolic acid, or 
chlorinated lime. Pieces of lint soaked in one of these solu- 
tions, may, with advantage, be left in contact with the ulcer, if 
the child will tolerate a fixed dressing. In case of perforation, 
much of the wash will run into the mouth, and care must be 
taken to prevent its being swallowed. The mouth must be kept 
as clean as possible by repeated syringings with a solution of 
chlorate of potassium and carbolic acid, ten grains of the former 
and one grain of the latter to the fluidounce. 

When recovery occurs, loss of tissue, and the deformities 
resulting from cicatricial contraction, may be, to some extent, 
remedied by plastic surgery. 



5. PARASITIC STOMATITIS— THRUSH. 

Thrush is characterized by the appearance of numerous, 
rapidly-growing, white, curd-like flakes upon the oral mucous 
membrane; the latter being in a more or less catarrhal condi- 
tion, injected, swollen, hot and tender to the touch. The flakes 
are due to the development of a peculiar vegetable parasite, the 



142 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

O'idium Albicans. Thrush occurs both as a primary and a sec- 
ondary affection. 

Etiology. — The disease attacks sucklings, and is met with 
most frequently during the first three months of life. Children 
nursed at a healthy breast are never attacked, and rarely those 
belonging to the well-to-do classes, because of the attention 
given to cleanliness of the mouth and feeding apparatus. 

Neglect of this fundamental principle, cleanliness, lies at the 
foundation of every case of primary thrush. Foulness of the 
mouth implies a condition in which the secretions and the food 
clinging to the mucous membrane are undergoing acid fermen- 
tation, a necessary precedent to the development of the fungus. 
Given this condition, thrush originates by contact with other 
cases, through the media of bottle tips, spoons, tumblers, or 
cups used in common, and is produced, de novo, by carelessly 
kept tips and bottles, and, more frequently still, by long nursing 
tubes which are always partially clogged, acid and ill smelling. 

The secondary form has the same direct causes, but arises 
during the course of gastro-intestinal disorders, especially those 
resulting from a too free dietary or the over-use of farinaceous 
food. It may occur, also, as a complication of diseases that 
greatly impair the general nutrition, as the exanthemata, tuber- 
culosis, scrofula, spinal caries, etc. The disease is most preva- 
lent during the summer months. 

The Morbid Appearances are the same in both forms. Prior 
to the appearance of the flakes, the oral mucous membrane is 
purplish-red and sticky, and its secretion is acid in reaction. 
The latter shows, under the microscope, numerous spores, egg- 
shaped, sharply-outlined, and hanging together in twos and 
threes. Soon, isolated white points, as large as a pin's head, 
appear on the inside of the cheeks. These rapidly increase in 
extent and number ; involve other parts of the mucous mem- 
brane, and often as early as the second or third day, large, white 
flakes are formed. Later still, the whole cavity of the mouth ; 
and, in some cases, even the pharynx and oesophagus are 
covered. 







^v 



& 






?■ 



vf 




<j. 



^j. 






I 

it 

s 
cvi 



AFFECTIONS OF THE MOUTH AND THROAT. 1 43 

The patches, at first white, may become yellow, and some- 
times brown, if bleeding occur from rough handling of the 
mucous membrane. Their surface is somewhat velvety, and they 
are soft, breaking down like curd under the finger. During the 
first few days they adhere firmly to the mucous membrane ; after- 
wards they become quite loose, and can be wiped off readily, 
leaving the epithelial surface intact. 

Microscopic examination of the fully formed patches reveals 
numerous irregularly developed fungoid filaments, with laterally 
branching arms and buds, interpersed with round or oval spor- 
ules, and imbedded in an amorphous, granular mass. A hard- 
ened section of a patch and the mucous membrane to which it 
adheres, shows, in addition to these characters, a partial loss of 
epithelium, and a tendency on the part of the filaments to 
penetrate into the mucous glands and between the cells of 
the deeper layers of the epithelium. 

The fungus seems to grow only upon squamous epithelium, so 
that it is never found in the nasal cavities, the larynx or the 
trachea, and the presence of loose masses of it in the stomach 
may be regarded as accidental. On the other hand it may be 
formed upon the lower segment of the rectum, the female 
genitals, and on abraded surfaces about the mouth, chin and 
neck. 

Symptoms. — The primary form begins with heat, dryness, 
tenderness, slight swelling and uniform redness of the mucous 
membrane of the mouth. The redness is combined with a 
purple tinge which is most marked on the dorsum of the tongue. 
Here, too, prominence of the fungiform papillae is noticeable. 
The child takes his food moderately well, but the meals are 
frequently interrupted on account of the pain caused by sucking. 
He is fretful and sleeps poorly. The bowels are moderately re- 
laxed, the stools being liquid and yellow in color. In the 
course of twenty-four hours the thrush patches appear on the 
inside of the cheeks and then extend to the lips, tongue and 
palate. While extending, they increase in size, though they 



144 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

usually remain isolated and rarely overstep the limit of the 
posterior border of the soft palate. With the appearance of the 
patches, there is increased fretfulness, more pain on sucking, 
occasional vomiting and frequent evacuation of the bowels, the 
motions becoming green and acid. At some period, varying 
from six to twelve days from the beginning of the disease, the 
patches become loose and are removed by the act of sucking or 
in making applications to the mouth. The mucous membrane 
is left red but free from ulceration, and it soon returns to the 
normal condition. At the same time the general symptoms 
subside, and health is soon restored. Sometimes there are 
several crops of the fungus, but those coming last, being less 
firmly rooted than the first, are dislodged quickly and seldom 
prolong the course of the disease beyond two or three days. 

In secondary thrush a history of previous gastro-intestinal or 
other disease will be obtained, together with an account of an 
immediately preceding diarrhoea and fever. Sometimes, how- 
ever, the local symptoms are the first indications that the weak, 
badly-nourished child is ill. The preliminary catarrh of the 
mouth is very marked, the mucous membrane being intensely 
red and shining. The patches are thick, are apt to change from 
a white to a yellow or brown color, soon cover the whole oral 
cavity and frequently extend into the pharynx and down the 
oesophagus. They retain their attachment to the mucous mem- 
brane for a much longer period than in the idiopathic form. 
When they fall off they are quickly replaced by others, and a 
succession of crops is the rule up to the termination of the case 
in death. The mouth is hot, dry and tender to the touch, and 
throughout presents an acid reaction to chemical tests. 

The appetite is gradually lost ; there is vomiting, either occa- 
sional or so constant that every morsel of food taken into the 
stomach is rejected at once, and obstinate diarrhoea, the stools 
being numerous, liquid, green in color and acid. The abdomen 
is distended by flatus, and is tender to pressure, particularly in 
the epigastrium and right iliac region. Colic is a constant and 



AFFECTIONS OF THE MOUTH AND THROAT. 1 45 

annoying symptom. The pain is most severe just before or at 
the moment of an evacuation of the bowels. 

The skin is hot and dry and the frequency of the pulse in- 
creased, a rate of 120, 140 or 160 beats per minute being not 
unusual. 

The child sleeps badly, is restless and fretful, and when the 
pharynx is covered by the fungus, has a muffled, hoarse cry. 
The skin grows pale and inelastic, and the folds of the nates, the 
inner surface of the thighs and the heels are reddened, and 
eventually excoriated by the contact of the acid faeces. The 
strength and flesh are lost rapidly, the anterior fontanelle sinks, 
the eyeballs lie deep in their sockets and the nose and chin are 
pointed. Toward the latter end of the attack, which is rarely 
protracted more than a few weeks, the patient assumes the facies 
of a little, wrinkled old man. His skin is cool, and he lies 
in an apathetic condition on the bed or nurse's lap, with scarcely 
enough strength to whine over his suffering until death, from 
atrophy, ends the miserable life. 

Diagnosis. — Fragments of curdled milk adhering to the soft 
palate and cheeks, resemble very closely the thrush patches in 
their earlier stage. The normal condition of the mucous mem- 
brane, and the readiness with which the curds can be wiped 
away, constitute the distinctive characteristics. 

Aphthous stomatitis bears a certain superficial likeness to 
thrush, but the differentiation is easily made by noting the fact 
that the yellowish-white spots of the former are depressed below 
the surface of the mucous membrane, being, in reality, the floors 
of ulcers, which in time are bounded by dark red borders. 
* Microscopic examination is always the crucial test, and the 
presence or absence of thallus-fibrils and spores decides the 
question as to the nature of any deposit in the mouth. 

Prognosis. — The primary form is a very trifling affection and 
almost uniformly ends in recovery. In the secondary form the 
result is very often unfavorable. This is especially apt to be the 
case when the disease occurs in a child who has been much 



146 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

weakened by a continued course of improper food. Here, the 
hope of improvement depends upon the rapidity and complete- 
ness with which new material for nutrition can be introduced 
into the system. Anything, therefore, that tends to prevent this 
introduction deprives the child of his only chance of recovery, 
and the existence of thrush implies a condition of the digestive 
tract extremely unfavorable to the assimilation of food. Attend- 
ant diarrhoea aids, too, in precipitating the fatal result. 

The mere presence, then, of the thrush patches is not to be 
regarded with as much anxiety as the conditions accompanying 
their formation. 

Treatment. — Much may be done to prevent the development 
of thrush by keeping the mouth clean. A strict rule should be 
made to wash out a child's mouth directly after each meal. This 
is best done by a large camel's-hair brush or a soft rag moistened 
with warm water. The bottles and tips must also be kept im- 
maculately clean. An equally important precaution is to select 
a proper diet. The question of diet is, of course, a very com- 
prehensive one, and no further consideration can be given it in 
this place than to state the general law. Babies under six months 
old, who are unfortunate enough to be deprived of their mother's 
milk, must be fed upon cows' milk so prepared that it may 
resemble as nearly as possible human milk. If farinaceous arti- 
cles be used they must be employed with the object of render- 
ing the cows' milk more digestible by separating the curd, and 
not as the staple of the food. The regularity and the length of 
the intervals between meals ; the selection of the proper quantity 
of food, and the preparation of each portion immediately before 
it is given, are matters worthy of the most careful attention.* • 

Such measures, together with attention to general hygiene, 
constitute an important part of the curative treatment after the 
appearance of the fungus. In idiopathic or in mild cases all that 
is required in the way of general treatment will be an alkali 

* See Part II. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 47 

combined with a digestant, as in the formula already given for 
catarrhal and aphthous stomatitis,* or if the stools be numerous, 
green and very acid : — 

R . Magnesii Carbonatis, gj. 

Syr. Rhei Aromatici, f ^ ij. 

Syrupi, f t ^ ss. 

Aq. Menthae Piperitae, . . . ■ q. s. ad f § iij. 

M. 

Sig. — Teaspoonful every two or three hours, for a child three 

to six months old. 

The local treatment consists in keeping the mouth perfectly 
clean. It should be thoroughly washed every hour at least, with 
a soft rag wrapped around the finger and wet with warm water. 
Immediately afterward, either one of the following lotions may 
be applied, upon a fresh piece of rag : — 

R . Sodii Boratis, gr. xxx. 

Glycerinae, f gj. 

Aquae, q. s. ad f^j. 

M. 

R. Sodii Hyposulphitis, gr. x. 

Aquae Rosae, fgj. 

M. 

R. Acid. Carbol., gr. ij. 

Sodii Salicylat., 

Sodii Boratis, aa , gr. xxx. 

Glycerinae, . . f^ij. 

Aquae Rosae, q. s. ad f Jj. 

M. 

It is essential immediately to destroy the rag or other instru- 
ment used in cleansing the mouth or in carrying the lotion. 

The same principles are applicable to the treatment of second- 
ary thrush. Every means must be employed to arrest the vomit- 
ing and diarrhoea, to improve the digestive powers and maintain 
the strength. There is, however, but one promising remedy for 
this form of the disease, namely, the employment of a healthy 
wet-nurse. 

* See page 126. 



148 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



6. DENTITION. 

ERUPTION OF THE TEMPORARY TEETH. 

The eruption of the twenty milk teeth may, like other physi- 
ological processes, be unattended by noticeable symptoms, but 
in many instances it is accomplished with difficulty, giving rise 
to disturbances which, on the one hand, may be so trifling as 
simply to annoy the infant, or on the other, so serious as to en- 
danger life. 

Fig. 6. 




Diagram showing Eruption of Milk Teeth. 

i. i. Between the 4th and 7th months. Pause of 3 to 9 weeks. 

2. 2. 2. 2. Between the 8th and 10th months. Pause of 6 to 12 weeks. 

3- 3- 3- 3- 3- 3- Between the 12th and 15th months. Pause until the 18th month. 

4. 4. 4. 4. Between the 18th and 24th months. Pause of 2 to 3 months. 

5. 5. 5. 5. Between the 20th and 30th months. 



Normally the teeth are cut in groups, each effort being suc- 
ceeded by a pause or period of rest. The above diagram and 
table show the grouping, the date of eruption, and the duration 
of the pauses. The numbers, i to 5, indicate the groups to 
which the individual teeth belong and their order of appear- 
ance, and the letters, a and b, the precedence of eruption in the 
different groups. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 49 

The dates given in the above table show the time within which 
the different teeth may be naturally expected. In regard to the 
period given for the eruption of the lower central incisors I 
would state that the fourth month, although an early, is not a 
very rare time for their appearance. For example, in the past 
winter alone, I have seen five cases in which these teeth pierced 
the gum at this age. 

The pauses mentioned are, to say the least, most helpful, giv- 
ing the infant's system an opportunity to rest after each effort, 
to recover from any coincident illness and to prepare for the 
next strain. 

Even under normal conditions the edges of the gums lose 
their sharpness and become swollen, rounded and reddened as 
the teeth approach the surface. At the same time the saliva is 
increased in quantity, and the mouth is unnaturally warm and 
the seat of abnormal sensations, evidenced by the tendency to 
bite upon any object that comes to hand — in other words, there 
is a condition of mild catarrhal stomatitis. The consequent dis- 
comfort, though, is not sufficient to interfere with the child's 
appetite, good humor, or sleep, and when, after a few days, the 
margin of the tooth is free, all the local symptoms vanish. 

Abnormal dentition is manifested either by departures from 
the laws of development already stated, or by actual difficulty in 
the process of cutting. 

The standard rules for the eruption of the teeth may be 
departed from in three ways : — 

1 st. The appearance of the teeth may be premature. Children 
may be born with one or more of their teeth already cut. These 
are usually imperfect, and soon fall out, to be replaced at the 
proper age by well-formed milk teeth. Sometimes, however, 
they remain permanently, as in a case that came under my own 
observation. Natal teeth are always incisors. Instances of the 
lower central incisors being cut in the third month are not un- 
common. Girls are more apt than boys to cut their teeth early, 
and, as an early dentition is likely to be an easy one, the occur- 
rence is to be looked upon as fortunate. 



150 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

2d. Dentition may be delayed. This deviation is more fre- 
quently seen and of more consequence than the first. Bottle- 
fed babies, as a class, are more tardy in cutting their teeth than 
those reared at the breast. With such, though healthy in every 
respect, a delay of one or two months is a common and not at 
all a serious event. On the contrary, whatever the method of 
feeding, if no teeth have appeared by the end of a year, it may 
be assumed that the child's general nutrition is faulty, or that 
rachitis is present. Delay does not necessarily imply difficulty 
in cutting the teeth, though the two conditions are often asso- 
ciated. 

3d. The teeth may appear out of their regular order. Bottle- 
fed infants are most likely to show this irregularity, which is of 
some importance as an indication of general feebleness. In 
other instances, however, it is merely a family peculiarity, and 
as such, bears no special significance. 

Difficult Dentition is attended by two classes of affections, 
viz. : local, and sympathetic or reflex. 

The third and fourth groups of teeth are most prone to make 
trouble, and when the child is born at such a time of the year as 
to bring their eruption during the hot months, illness of some 
sort may be anticipated. This is often dangerous, sometimes 
fatal, hence the popular dread of the " second summer." 

Local Affections. — Catarrhal stomatitis, already referred to 
as a physiological occurrence, frequently becomes greatly in- 
tensified, and is sometimes associated with enlargement of the 
submaxillary and cervical lymphatic glands. Aphthous and 
ulcerative stomatitis develop much more rarely. 

Ulceration of the fraenum linguae often takes place after the 
cutting of the first lower incisors, being due to direct and con- 
tinuous friction of the sharp, new teeth. Usually a single, flat, 
round ulcer, the size of a linseed, is formed. The base is yellow 
and lardaceous, the edges red and infiltrated. At times it is suffi- 
ciently painful to interfere with the movements of the tongue, 
though at others so indolent as to escape notice entirely. Such 



AFFECTIONS OF THE MOUTH AND THROAT. 151 

ulcers, if left to themselves, disappear in from eight to ten days. 
Their course may be much shortened by touching them lightly 
with a point of nitrate of silver, and then applying a solution of 
chlorate of potassium three or four times each day. 

Another very common condition is an excessive increase in the 
secretion of the fluids of the mouth, attributable to irritation of 
the mucous and salivary glands. The constant driveling of this 
fluid reddens and excoriates the skin of the chin and anterior 
part of the neck. It also soaks the clothing ; and the consequent 
chilling of the thorax both excites and tends to keep up a 
catarrhal state of the bronchial and mucous membrane. In this 
way may be explained the frequent concurrence of driveling and 
severe cough in teething children. The etiological association is 
further proven by the fact that if the chest be protected by a piece 
of oiled skin or other waterproof material, placed inside of the 
clothing, the cough either does not develop or quickly disappears 
if it has been present. If these two results are excepted, slob- 
bering is not to be regarded as unfavorable, for such children 
rarely have alarming brain symptoms, or severe intestinal catarrh. 

The Sympathetic Effects of difficult dentition show them- 
selves in affections of the eyes and ears, gastro-intestinal dis- 
orders, skin eruptions, nervous affections, and fever. 

Conjunctival blennorrhea arises frequently during the eruption 
of the upper canines; hence the common name, " eye-teeth. " 
This complication may be attributed to an extension of irritation 
to the antrum of Highmore, the nasal passages, and, finally, to 
the conjunctiva. The eyelids swell greatly and rapidly, there is 
difficulty in opening the eye, a free secretion of a stringy, trans- 
lucent mucus, and pain and photophobia ; the ball remains intact. 
It is distinguished from true blennorrhcea by frequently being 
unilateral, by ils non-contagiousness, and by the absence of the 
characteristic, dark-yellow, thick, purulent discharge. Recovery 
quickly follows the appearance of the point of the tooth, and no 
treatment is required beyond cleanliness and the application of 
dry warmth. 

Otitis is not uncommon. It is probably due to irritation con- 



152 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

veyed from the inflamed gum to the otic ganglion, and thence 
deflected to the vessels supplying the tympanic membrane. In 
consequence, this membrane becomes congested, and there is 
great pain. When the irritation persists, suppurative inflamma- 
tion is developed in the tympanic cavity, the drum is perforated, 
and pus flows from the external auditory meatus. The treatment 
belongs to the domain of aural surgery. 

Simple diarrhoea, with yellow, pultaceous or somewhat green- 
ish stools, is a very common occurrence. It is due either to an 
intestinal catarrh of mild grade, or to the swallowing of large 
quantities of saliva, the saline constituents of which act as laxa- 
tives. Under ordinary circumstances, attention to the diet is all 
that is necessary for its relief. If vomiting be associated or the 
stools be green, bicarbonate of sodium, carbonate of magnesium, 
or subcarbonate of bismuth, with an aromatic, may be ordered, 
and if there be griping it is well to clear out the bowels by a dose 
of castor oil. Opium and powerful astringents are to be avoided. 

While the diarrhoea of teething is ordinarily of little moment 
it should receive careful treatment, for there can be no doubt 
that during dentition the mucous membrane of the digestive 
tract, sympathizing in the oral irritation, becomes more suscep- 
tible to such irritants as badly digested or improper food, and 
that a condition of simple catarrh is apt, under such influences, 
to pass into one of follicular enteritis, with secondary involve- 
ment of the mesenteric glands. This is soon followed by 
general atrophy (marasmus), frequently terminating in death. 
Hand-fed infants are particularly prone to be so affected. The 
symptoms are vomiting, the formation of thrush deposits in the 
mouth, anorexia, thirst, tympanitic distention of the abdomen, 
diarrhoea, and rapidly increasing emaciation. The very numer- 
ous faecal evacuations are liquid, have a penetrating, cadaverous 
odor, and excoriate the anus and surrounding parts. This 
condition demands, and too often resists, the most careful 
treatment. * 

* See sections on the diseases attended hy diarrhoea. 



AFFECTIONS OF THE MOUTH AND THROAT. 153 

When vomiting occurs as a complication, it may often be re- 
lieved, in sucklings, by shortening somewhat the time the child 
is allowed to lie at the breast, and thus preventing over-disten- 
tion of the stomach. With hand-fed infants the same result may 
be attained by judiciously lessening the quantity of food given at 
each meal and reducing its strength, by the addition of lime- 
water. A teaspoonful of lime-water every half hour or hour will 
aid in checking the vomiting, and the following prescription is 
excellent : — 

R . Liq. Calcis, 

Aq. Cinnamomi, aa f^j. 

M. 

S. — One teaspoonful every half hour or hour, for a child of 
seven months. 

Several forms of cutaneous eruption attend difficult dentition. 
They usually appear in children with fair, delicate skins, show 
some hereditary and family tendency, and must be considered 
of vaso-motor origin. 

The eruption may be present during the cutting of one set of 
teeth only, or may continue during the entire dentition. In the 
latter case it improves greatly or disappears in the pauses. The 
form usually remains unchanged throughout. 

The varieties that may exist are : — 

(a) Urticaria. — This consists of the appearance of a varying 
number of wheals, chiefly on the trunk and extensor surfaces of 
the limbs. The wheals are slightly prominent, flattened eleva- 
tions of the cuticle, varying in size from that of a pea to a bean, 
somewhat paler than the normal skin, but surrounded by red 
areolae gradually fading at the periphery into the healthy skin 
color. They develop suddenly, making their appearance espe- 
cially when the child becomes warm in bed, or is overheated, 
and are the seat of some burning and intense itching. They 
last a few hours, and disappear rapidly, leaving the epidermis 
intact, except for accidental injuries occasioned by scratching. 

Relief comes after a careful regulation of the diet. If the 
child be bottle-fed the milk must be w r ell guarded with lime-water. 

!3 



154 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

If older, and fed on mixed food, it is well to avoid farinaceous 
articles. The bowels, usually constipated, should be regulated 
by saline laxatives, and much benefit will result from the use of 
effervescing citrate of potassium, in doses of one-fourth of a tea- 
spoonful (equal to gr. v), three times daily, for a child of eight 
months to a year old. The most soothing local application is : — 

R. Sodii Hyposulphitis, ^ ij-iv. 

Aq. Rosae, f 5 xvj. 

M. 

This is to be sponged over the wheals at short intervals or ap- 
plied by moistened compresses. 

(^) Strophulus. — This presents itself in two forms, strophulus 
intertinctus or red gum, and strophulus albidus or white gum. 

Red gum consists of an eruption of prominent, red papules, 
interspersed with small patches of erythema. The papules are 
scattered over the whole body, but are most abundant on the 
face, back of the hands and forearms ; they vary considerably in 
size, though they are rarely larger than a pin's head ; they are 
the seat of considerable itching, and after their disappearance 
there is trifling desquamation. It occurs in successive crops, each 
crop lasting from seven to fourteen days. 

In white gum the papules are pearly-white instead of red, and 
each elevation is surrounded by a faint red areola. These papules 
are most numerous on the face, neck and breast ; they are smaller 
than those of the former variety, but like them appear in crops, 
which remain about seven days. 

With the exception of attention to digestion, which is often 
deranged, little treatment is required. Dusting with bismuth or 
lycopodium, or anointing with cold cream or simple cerate will 
relieve the itching. 

{c) Eczema* — In teething children this affection may be 
found in any one of its various forms. It may extend over the 
entire surface or be limited to a small area; its usual position, 
however, is the face and scalp. 

* This is the form of skin disease usually covered by the term " tooth rash." 



AFFECTIONS OF THE MOUTH AND THROAT. 155 

Facial eczema begins with redness, induration and roughness 
of one or other cheek. There is also intense itching, and even 
at this early stage the child, if unhampered, will scratch the 
affected part until it becomes raw and bleeding. Soon minute 
vesicles or pustules form. 

If the dermatitis be slight the eruption is vesicular. The 
vesicles may heal spontaneously, or being broken mechanically, 
they discharge a serous fluid which dries into thin scales or lamel- 
lated crusts. These fall off, leaving a reddened, moist, delicate 
surface, still intensely itchy, and soon to be covered by another 
crop of vesicles, which undergo the same changes. 

If the inflammation of the skin be more severe, the eruption 
is pustular. The pustules on breaking, exude a material that 
dries into thick, yellowish-brown crusts, often extensive enough 
to cover the whole face, except the eyelids and nose, as with a 
mask. In hardening, cracking is apt to occur, with the exposure 
of the red and bleeding derm. When the crusts fall, or are 
scratched off, an intensely red, weeping surface is left, which 
is soon recovered by thinner, lighter-colored crusts, resembling 
those seen in the vesicular form. The neighboring lymph glands 
are always somewhat enlarged and tender. The process of 
crusting and cleaning off repeats itself again and again, fre- 
quently dragging through the entire dentition, though subject to 
improvement or even completely healing during the pauses. 

Sometimes, especially toward its close, the eczema assumes the 
papular form. 

The disease is attended by sensations of discomfort and tension 
about the face. The itching is continuous but subject to exacer- 
bations in which it is most difficult to keep the child from tearing 
the skin with his nails. One often leaves a patient with his face 
covered by a thick crust, to find him at the next visit with 
clean, red and moist cheeks scarred by nail-scratches, from which 
the blood drops upon his clothing. The exacerbations occur 
chiefly at night. Under the circumstances it is but natural that 
the little sufferer should be restless and peevish, should sleep badly 9 
and, from the latter cause, should gradually fail in health and 



156 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

strength. The appetite, too, is often diminished, the digestive 
powers impaired, and the bowels confined. There may be slight 
febrile reaction toward evening. 

Eczema of the scalp — crusta lactea — involves at first only a 
small area, but has a marked tendency to spread. In some 
cases it appears in the form of minute, disseminated vesicles ; 
these break and exude their serous contents, which harden into 
thin, scaly crusts. If these be removed the skin beneath will be 
found to be reddened and moist. In others the vesicles rapidly 
change into pustules, and when these are broken the puriform 
fluid dries into thick, yellowish-brown crusts. The underlying 
skin is red, swollen, and painful, and the source of a constant 
formation of pus, which in drying adds to the thickness of the 
preexisting crusts. These mat the hairs together, become, day 
by day, thicker, harder on the external surface and darker in 
color, from the admixture of dust or of blood flowing from 
wounds caused by scratching. As the hair grows it lifts the 
crusts from the scalp and the pus finds its way out, running over 
and excoriating the skin of the forehead and neck. From the 
heat of the head and exposure to the air partial decomposition 
sets in, attended by a disgusting odor, and in carelessly kept 
children myriads of lice appear. In well-marked instances the 
crusts completely encase the scalp. The occipital and other 
lymphatic glands are usually enlarged, and occasionally, in stru- 
mous children, suppurate. Crusta lactea is no less obstinate than 
facial eczema. When it runs a protracted course the hair may 
fall out, but the loss is not permanent. 

There can be no question as to the propriety of healing eczema 
of the face or scalp as quickly as possible. The idea that the cure 
of the rash leads to more serious mischief, as meningitis or hydro- 
cephalus, is merely a remnant of the long abandoned doctrine 
that disease is due to the presence of an evil spirit, which if driven 
from one place will attack another. The objections of some self- 
important and misinformed parents to any local application will 
usually be overcome by the assurance that the eruption is not to 
be driven in, but cured as it comes out. 



AFFECTIONS OF THE MOUTH AND THROAT. 157 

Under the best of conditions, however, tooth rash is difficult 
to cure, and requires both general and local treatment. 

The general treatment demands in the first place attention to 
the diet. Bottle-fed babies must have their milk well alkalinized 
with lime-water, and older children must avoid farinaceous and 
heavy food. Next, conditions of acid dyspepsia, which, by the 
way, frequently exist, must be corrected by alkalies. Then it is 
essential to keep the bowels freely moved \ for this purpose the 
following mixture answers well : — 

R . Magnesii Carbonatis, 

Mannae Opt., aa gr. xl. 

Ext. Sennae Fid., tt^lxxx. 

Syr. Zingiberis, . . fj ss - 

Aquae, q. s. ad f 5j. 

M. 
S. — One teaspoonful once or twice daily, for a child seven months to 
a year old. 

Finally, certain medicines may be used with advantage. The 
emulsion of cod-liver oil and lacto-phosphate of lime in debili- 
tated, strumous or rachitic children ; syrup of the iodide of iron 
in the anaemic; Fowlers solution when the eruption becomes 
chronic. 

For the successful local treatment of facial eczema it is neces- 
sary to have many resources at command ; to make frequent 
changes as the applications lose their beneficial effects, and to 
persevere in spite of discouragement. Little progress will be 
made if the child be allowed to scratch the face at will. During 
the waking hours this is to be prevented by careful watching and 
diversion on the part of the nurse. At night by muffling the 
hands in thick, soft cloths, or by wrapping a napkin around the 
body in such a manner as to confine the arms, or, better still, by 
fixing the lower ends of the night-gown sleeves to the diaper, 
with safety-pins. The latter arrangement allows of some move- 
ment of the bands but prevents their being lifted to the face. 
The child quickly becomes accustomed to the partial restraint. 



L$8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

As soon as redness, induration and roughness of the skin indi- 
cate the onset of the disease, a mucilage made from sassafras pith 
(never musty or sour), is to be mopped over the surface with a 
soft rag, at intervals of an hour, or less. After this has dried 
for five minutes, a thick layer of the ointment of the oxide of 
zinc should be gently applied with the finger. If the officinal zinc 
ointment increase the inflammation, as it sometimes does in 
young or delicate-skinned babies, it must be diluted one-half, or 
even three-quarters, with cold cream. The nose, eyes and lips 
should be kept clean by wiping them with a moistened cloth, 
but the affected portions of the face must never be washed. Both 
the mucilage and ointment greatly relieve the itching, and in 
mild cases are sufficient to effect a cure. 

When vesicles or pustules become abundant, zinc ointment is 
still most serviceable, though it is no longer well to use the muci- 
lage. When the former ceases to be of service, one of the fol- 
lowing may be tried : — 

&. Cerat. Plumbi Sub-acetatis, gij. 

Ung. Aquae Rosae, • • 3 v j- 

M. 

R. Bismuthi Sub-nitratis, 3.HJ- 

Adipis, ^vj. 

M. 

R. Glycerinae, f^ij. 

Adipis, ^vj. 

M. 

R . Olei Lini, 

Liquor. Calcis, aa fgj. 

M. 

R . Acidi Salicylici, 3 ss. 

Adipis, gj. 

M. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 59 

The first three are more sedative than zinc ointment, the last 
two more stimulating. 

Hebra's diachylon ointment, useful in very moist eczema, is 
prepared in the following way: — 

R. Olei Olivae, fgj. 

Lithargyri, , . . gij. 

Coque 1. a. in molle, dein adde. 

Olei Lavandulae, Tt\viij. 

M. 
S. — Rub the ointment over the affected spot two or three 
times daily, or, better, apply upon linen compresses. 

When the patient does not bear salves well, a paste of oxide of 
zinc with glycerin may be ordered, and sometimes a dusting 
powder is beneficial, as : — 

R. Zinci Oxidi, 3J. 

Amyli, . gj. 

M. 
S. — Dust over the affected part frequently. 

In such cases, too, lotions act well. For example, the officinal 
liquor plumbi sub-acetatis dilutus, or :— 

R . Zinci Sulphatis, gr.j.-ij. 

Aquae Rosae, f g j. 

M. 

R . Sodii Boratis, gr.v.-x. 

Glycerinae, f ;jj. 

Aq. Rosae, q. s. ad fgj. 

M. 

In chronic cases, especially where there is hypertrophic 
thickening of the corium, a tendency to the squamous form, 
and but little redness, wonderful results will be obtained by 
using either — 

R. Ung. Hydrargyri Ammoniati, ^ j— Iv. 

Ung. Aquae Rosae, q. s. ad gj. 

M. 
S. — Apply three or four times daily. 



l6o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Or this lotion — 

R. Hydrargyri Chloridi Corrosivi, gr.j — ij . 

A q use > ffj. 

M. 
S. — To be penciled over the affected surface two or three 
times daily. 

A great point in the treatment is to continue the local 
applications, not only until the eruption has disappeared, but until 
the skin has become perfectly smooth, soft and altogether normal. 
Again, to begin the applications early, as the ease and quickness 
of cure is in proportion to the acuteness and scantiness of the 
eruption. 

Crusta lactea may be cured with more or less rapidity by 
cropping of the hair, softening the crusts with olive oil, apply- 
ing a poultice of flaxseed over night, and using an ointment 
containing mercury, as — 

R. Ung. Hydrargyri Nitratis, 3J-ij- 

Ung. Aquae Rosse, q. s. ad gj. 

M. 
S. — Rub into scalp three times daily. 

H. Hydrargyri Chloridi Mitis, gr. xxx. 

Cosmoline, ^j. 

M. 

In some instances penciling with the solution of corrosive sub- 
limate, already mentioned, gives better results. 

When there is intense redness of the scalp, it is often best to 
begin with oxide of zinc ointment, reserving the mercurial pre- 
parations until the inflammation is lessened. When the disease 
becomes chronic, with thickening of the skin, loss of hair, and 
the assumption of the squamous form, more stimulating applica- 
tions are indicated, for instance — 

R . Ung, Picis Liquidse, 

Adipis, aa ^iv. 

M. 
S. — Apply thrice daily. 



AFFECTIONS OF THE MOUTH AND THROAT. l6l 

R. Saponis Mollis, giv, 

Alcohol dil., f ^ ij. 

Spt. Lavandulae, tt\,xv. 

M. et cola. 
S. — Rub into the skin by means of a piece of flannel or a 
brush, to remove scales, etc. 

Inunctions of cosmoline and vaseline are often most beneficial 
in eczema, and the latter is a good vehicle for the preparations 
of mercury, zinc, lead, etc. 

The most dangerous of all the complications attending diffi- 
cult dentition are the disturbances of the nervous system. These 
are due to a great increase in the normally excessive susceptibility 
of the infantile nervous system to reflex influences. They em- 
brace slight spasms of isolated groups of muscles and general 
convulsions. 

Slight spasms are very common, and are observable chiefly 
during sleep. They are revealed by upturned eyeballs, and half- 
open eyelids, exposing more or less of the whites of the eyes ; 
by contraction of the muscles of the face, causing a smile, and 
by twitching movements of the fingers and limbs. These mani- 
festations can be prevented and sound sleep secured, by a warm 
foot-bath at bedtime, with five or ten grains of bromide of 
potassium. 

A general convulsion arises suddenly and unexpectedly, and 
generally begins with tonic spasm of the muscles. The head is 
thrown back, the spine arched forward, the limbs become rigid, 
and breathing is suspended. Soon clonic movements set in ; 
the face, which is flushed, becomes distorted ; foam, sometimes 
bloody, appears upon the lips ; the limbs are jerked about ; the 
trunk writhes ; the respiration is unrhythmical and sighing, and 
consciousness is completely lost. After a time, as the convulsion 
ends, the face becomes pale, the lips bluish, and the skin moist. 
There may be but a single convulsion, lasting a few moments, 
or there may be a number, varying in duration, and following 
each other at longer or shorter intervals. In some cases, the 
14 



162 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

child remains in a convulsed condition for several days, passing 
from one fit into another, with only brief intervals of imperfect 
calm. Often they pass off without leaving any traces, but may 
be followed by paralysis, strabismus or idiocy, and may terminate 
in death. 

The treatment consists in removing pressure from the gums by 
the use of the lancet, and the employment of nerve sedatives, as 
chloral and bromide of potassium. Should it be impossible for 
the patient to swallow, these drugs may be administered by the 
rectum, in the following enema : — 

I£ . Chloral Hydrate, gr.xij. 

Potassii Bromidi, ^ss. 

Mucilag. Acaciae, fgj. 

Aquae, q. s. ad fjjiij. 

M. 
S. — One tablespoonful for a dose. 

The injections are to be repeated every half hour — at the age 
of one year — until the convulsive movements are checked, or 
three or four doses are given. If this quantity fail, it is better to 
omit the chloral for two hours, and then resume it as before ; in 
the meanwhile continuing the bromide of potassium. 

So-called dental paralysis is uncommon, and when it does 
occur can usually be traced to coincident anterior polio-myeli- 
tis. It is sudden in its onset. After a restless night the child 
wakes with one arm helpless, or with one arm and one leg power- 
less ; more infrequently one arm and both legs, or both arms are 
affected. The means for relief are salt-water baths with fric- 
tions, attention to the general health, and the use of tonics. 

Elevations in temperature, with other evidences of slight 
febrile reaction, are very common during teething. The 
pyrexia is of short duration, moderate in degree, and readily 
controlled by hot foot-baths, and diaphoretics, as tincture of 
aconite root in small doses, or citrate of potassium. 

In both classes of affections arising from difficult dentition, 
the question of the propriety of lancing the gums often arises. 



AFFECTIONS OF THE MOUTH AND THROAT. 163 

Many authorities advise postponement of incision until the gum 
becomes swollen, tense and shining, and the edge of the tooth 
is perceptible to the touch, just beneath the mucous membrane, 
or until yellowness of the gum and fluctuation indicate the forma- 
tion of pus about the approaching tooth. This rule applies 
merely to cases in which there is little difficulty. For in many 
instances the greatest discomfort and danger are present while the 
tooth is yet some distance from the edge of the gum, forcing its 
way through the deeper and denser tissues. Here the only safe 
course is to cut deep, and liberate the tooth, repeating the opera- 

Fig. 7.* 




Diagram of Lines of Incision in Lancing the Gums. 

The above diagram plainly shows the lines of incision over the different teeth before erup- 
tion and after partial eruption. 

tion if the original incisions heal — -an event of little moment. 
My own practice in regard to lancing is guided entirely by cir- 
cumstances. If there be fever, nervous irritability, sleeplessness, 
vomiting or diarrhoea during the progress of and dependent upon 
dentition, I invariably lance the gum, — provided the position of 
the tooth can be established by the touch — making the incision 
superficial or deep, according to the distance of the tooth from 
the surface. I feel confident that no one who has once 

* From " Diseases Incident to First Dentition." James W. White, M. D., 

D. D. S. 



164 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

attempted early lancing, and observed distressing and dangerous 
symptoms rapidly disappear, will ever hesitate a second time. 

The form of incision is important. It must be linear in the 
case of the incisors and canines, and obliquely crucial in that of 
the molar teeth; the tissues must be divided until the edge of the 
lancet distinctly touches the tooth. 



ERUPTION OF THE PERMANENT TEETH. 

The eruption of the milk teeth, though physiological, as 
already stated, is so uniformly regarded as dangerous, that both 
physicians and parents congratulate themselves when infants 
under their charge pass through this process without trouble, or 
safely weather the various diseases that may arise during its course. 
The interval between the fourth and thirtieth months of an in- 
fant's life — the period of primary dentition — is an era of great 
and widely extended physical progress. The teeth are advancing ; 
the follicular apparatus of the stomach and intestinal canal is un- 
dergoing development in preparation for the digestion and absorp- 
tion of mixed food ; the cerebro-spinal system is rapidly growing 
and functionally very active, and the organs and tissues of the 
whole body are in a state of active change. This period of nor- 
mal transition must also be one in which there is great suscepti- 
bility to abnormal change, or disease, provided there be a causal 
influence at work. Such an influence may either originate out- 
side of the body, as when there is exposure to cold, or to conta- 
gion, or come from within in the form of some perversion of a 
physiological process. 

Difficult dentition stands prominent in the latter class. While 
the teeth are advancing, irritation of the gums very often pro- 
duces stomatitis with fever, and the fever in turn leads to en- 
feebled digestion and impaired nutrition, conditions that open 
the way to catarrh of the mucous membrane of the bronchial 
tubes and gastro-intestinal tract, and to other intercurrent affec- 
tions. Again the local irritation may be reflected through the 
widely extended connection of the dental nerves, and give rise to 



AFFECTIONS OF THE MOUTH AND THROAT. 1 65 

well-known disorders of distant organs, and tissues, for example, 
the brain, eyes, stomach, skin, and so on. 

To appreciate this widely-extended nervous connection, it is 
only necessary to study Plate i. This, which, by the way, is 
purely diagrammatic in character, illustrates the intimate anatomi- 
cal relations existing between the trifacial, pneumogastric, and 
glosso-pharyngeal nerves, through the medium of the superior 
cervical ganglion of the sympathetic and its branches. This gan- 
glion sends a branch directly to the jugular ganglion of the 
pneumogastric ; another branch subdividing, sends one filament 
to join the ganglion of the root of the pneumogastric, while the 
other goes to the petrous ganglion of the glosso-pharyngeal, and, 
finally, branches pass between it and the ganglion of the trunk of 
the par vagum. Two ascending branches from the cervical gan- 
glion pass to the internal carotid to form the carotid and cavern- 
ous plexuses ; from these plexuses a filament passes to the under 
side of the ophthalmic branch of the fifth nerve, a second connects 
with the ophthalmic ganglion, while other communications with 
the ophthalmic nerve are formed by a branch passing between the 
ganglion and nasal branch of the ophthalmic, and the branch of 
the ophthalmic to the inferior oblique muscle. From the internal 
carotid plexus a filament reaches the spheno-palatine ganglion con- 
nected with the superior maxillary through the Vidian nerve. Fila- 
ments pass to the external carotid, forming a plexus from which 
those of the middle meningeal and facial arteries are derived. 
From the middle meningeal plexus a filament passes to the optic 
ganglion, which is connected with the inferior maxillary nerve, 
while from the facial plexus a branch reaches the submaxillary 
ganglion, which, in turn, is connected by several filaments with 
the gustatory branch of the trifacial nerve. Other communications 
exist between the Casserian ganglion and the cavernous plexus, 
the otic ganglion and the glosso-pharyngeal nerve, etc., etc. 

Next let us trace the routes of transferred irritation. 

1. Stomach. — Nerve supply of stomach from terminal 
branches of the right and left pneumogastric and from the sym- 
pathetic. 



1 66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Irritation from the upper teeth travels, by means of the dental 
branches of the superior maxillary to the trunk of the superior 
maxillary division of the fifth pair, by the spheno-palatine branches 
of this nerve to Meckel's ganglion, and from this ganglion to 
the carotid plexus of the sympathetic. The carotid plexus being 
in connection with the superior cervical ganglion of the sympa- 
thetic, the irritation is transferred to the sympathetic branches 
which go to the stomach ; and as it sends filaments to the jugular 
ganglion of the pneumogastric, the irritation reaches the gastric 
terminations of the vagus (or to Casserian ganglion, to carotid 
plexus, to superior cervical ganglion). 

Irritation from the lower teeth passes by the superior dental 
branches of the inferior maxillary to the trunk of the nerve. 
This nerve, by its auriculo-temporal branch, is joined to the otic 
ganglion, and the irritation, after leaving this ganglion, reaches 
the meningeal plexus, is transferred to the superior cervical 
ganglion, and then reaches the stomach by the route above in- 
dicated. 

Or, by trunk of nerve to Casserian ganglion, from this to 
carotid plexus and from this to superior cervical ganglion. 

2. Intestines. — Same route as above to superior cervical 
ganglion, and from this by means of sympathetic to the intestines. 

3. Glands of Neck. — An irritation from the teeth which 
reaches the superior cervical ganglion, passes by the outer branches 
of this ganglion to the four upper cervical spinal nerves. Also 
passes to middle cervical ganglion and by its outer branches to 
the fifth and sixth spinal nerves. Also passes to inferior cervical 
ganglion to seventh and eighth cervical nerves. These nerves 
are the chief source of supply for the cervical lymphatics. 

4. Salivary Glands. — To Parotid. — An irritation from 
upper teeth is transferred to Meckel's ganglion by spheno-pala- 
tine branches and from this to carotid plexus, which plexus sends 
filaments direct to parotid gland. 

An irritation from the lower teeth reaches the gland by means 
of the inferior dental branches of the inferior maxillary trunk of 



AFFECTIONS OF THE MOUTH AND THROAT. 1 67 

the inferior maxillary, auriculotemporal branch and parotid 
branches. 

Or, as before shown, by the superior cervical ganglion and 
the carotid plexus, which sends filaments to the gland. 

To Submaxillary. — An irritation from the upper teeth 
passes by dental branches and trunk of superior maxillary to 
Casserian ganglion, from this to carotid plexus, from this to 
plexus on facial artery, and then to gland. 

Or, from Casserian ganglion to gustatory branch of inferior 
maxillary, and by branches of this nerve to the gland. 

Irritation from lower teeth by inferior dental branches and 
trunk of inferior maxillary to Casserian ganglion, and from this 
by gustatory and branches to submaxillary ganglion and gland. 

Also, by mylohyoid branches of the inferior dental to gland. 

To Sublingual. — From upper teeth by dental branches and 
superior maxillary to Casserian ganglion, and from this by gus- 
tatory and branches to gland. From lower teeth by dental 
branches and inferior maxillary to Casserian ganglion and from 
this by gustatory and branches to gland. 

5. Lungs. — Nerve supply from anterior and posterior pul- 
monary plexuses formed by branches from sympathetic and 
pneumogastric reaches the superior cervical ganglion as indi- 
cated in No. 1, and is, as there shown, transferred to pneumo- 
gastric and sympathetic. 

6. Eyes. — Irritation reaches carotid plexus from upper teeth 
as shown in No. i. Filaments from carotid and cavernous 
plexuses to nerves of the eye. A filament to the under side of 
the ophthalmic division of the fifth pair. Another joins the oph- 
thalmic ganglion, and branches pass between this ganglion, the 
nasal branch of the ophthalmic, and the branch of the ophthalmic 
which goes to the superior oblique muscle. From the carotid 
plexus come filaments to the abducens nerve. Irritation from 
lower teeth to superior cervical ganglion, as shown in No. i. 
From here to carotid and cavernous plexuses, and to eye as 
above. 



1 68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

7. Ears. — Irritation from upper teeth to Meckel's ganglion as 
in No. 1. Meckel's ganglion by Vidian supplies part of mucous 
membrane of Eustachian tube, branches of it join the facial and 
the facial sends branches to the laxator tympani and stapedius. 

Or, to superior cervical ganglion, as in No. 1. To the glosso- 
pharyngeal, to its petrous ganglion, and to Jacobson's nerve, 
which supplies the fenestra rotunda, fenestra ovale, and lining 
membrane of Eustachian tube and tympanum. 

Or, from superior cervial ganglion to ganglion of pneumo- 
gastric, and by Arnold's nerve to external auditory meatus and 
membrana tympani. 

Or, to superior cervial ganglion, to carotid plexus, and from 
this to tympanum. 

From lower teeth by dental branches, as in No. 1, and in- 
ferior maxillary to otic ganglion, and from this a branch goes to 
tympanum. 

Or, to otic ganglion, from this to meningeal plexus, from this 
to superior cervical ganglion, and from this to carotid plexus and 
tympanum. 

Or, to Casserian ganglion, from this to carotid plexus, and 
from this to tympanum. 

8. Larynx. — Nerve Supply. — Superior laryngeal branch 
of pneumogastric and recurrent laryngeal branch of pneumo- 
gastric and sympathetic reaches pneumogastric and sympathetic 
as in No. 1. 

With these conditions fully recognized it is surprising that 
second dentition has not been accorded the position it deserves, 
as a cause of ill-health in later childhood. In second dentition 
the elements of local irritation with fever are quite as potent as 
before. There is, however, less activity of development or 
rapidity of change, if we except the radical alteration in the 
system occasioned by the approach of puberty. Therefore there 
must be less susceptibility to disease, and this fact, taken with the 
greater resisting power of advancing age, fully accounts for what 
every observer will find to be true, namely, that the disorders of 
this period are less frequent and, as a rule, less dangerous than 



AFFECTIONS OF THE MOUTH AND THROAT. 1 69 

those that attend the cutting of the milk teeth. Nevertheless the 
etiological relations of the eruption of the permanent teeth will 
fully repay a careful study. 

The subject will be considered here in its relation to the time 
between the fifth year and the establishment of puberty, when 
childhood is over, and youth or maidenhood begins. 

The permanent teeth are cut in the following order : — 

(1) Four first molars, five to six years. 

(2) Four central incisors, six to eight years. 

(3) Four lateral incisors, seven to nine years. 

(4) Four first bicuspids, nine to ten years. 

(5'^ Four second bicuspids, ten to twelve years. 

(6) Four canines, eleven to thirteen years. 

(7) Four second molars, twelve to fourteen years. 

(8) Four posterior molars (or " wisdom teeth/ ' not entering 
into this study), seventeen to twenty-one years. 

Of the twenty-eight teeth cut within the period already men- 
tioned — the fifth to the fifteenth years — the first and seventh sets 
are developed de novo, and are more likely to give rise to 
trouble, particularly of the oral mucous membrane. The other 
sets take the place of corresponding milk teeth, and appear in 
very much the same order, the lower central incisors appearing 
before the upper, the upper lateral incisors before the lower, the 
upper bicuspids before the lower, etc. 

Fig. 8 will aid in explaining the process. 

As these teeth approach the surface, absorption begins in the 
alveoli and at the roots of the deciduous teeth, and this continues 
until the teeth are loosened and readily extracted, or if this be 
not done, until little is left but their crowns. 

When the first and second molars approach the surface, the 
gums, just as in primary dentition, become red, swollen, rounded 
and tender. The salivary secretion is increased, the mouth is 
hot, the patient complains of aching in the gum, and, on account 
of tenderness, refuses food requiring mastication. With the other 
sets there is a gradual loosening of the superimposed temporary 
teeth, pain on mastication, redness and tumefaction of the gum, 



170 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



and augmented flow of saliva. As there is no impairment of the 
general health, these trifling symptoms must be regarded merely 
as manifestations of the progress of a physiological process. Such 
are the normal manifestations. 

The most common disorders of second dentition, are (a) those 
of the mouth and throat ; (//) of general nutrition ; (7) of the 
stomach and intestinal canal ; (</) of the cervical lymphatic 
glands; (<?) of the eyes; (/) of the ears; (g) of the skin; {h) 
of the respiratory tract ; (/) of the nervous system. 

(a) Oral pain is often intense. It is lancinating or neuralgic 

Fig. 8. 
A> 3 3 * 




LiUL 



CP&&a(u ^ 





4- 2 2 4? 6 

Diagram showing Relation between the Permanent and Temporary Teeth. 
The figures i, 2, 3, etc., indicate the groups of teeth and the order of their appearance. 

in character and may either be limited to the position of the 
advancing tooth or extend throughout the upper and lower jaws 
— the region supplied by the dental branches of the trifacial 
nerve. Sometimes the pain is referred to the eye, the ear, the 
face, or even to the forehead. Pain associated with tenderness 
most frequently attends the eruption of the first molars ; then 
there is also redness and marked swelling of the gum, as in pri- 
mary dentition. 

The redness and swelling about an advancing tooth or around 



AFFECTIONS OF THE MOUTH AND THROAT. 171 

a loosened milk tooth may, in debilitated or strumous subjects, 
extend to the mucous membrane of the whole mouth and give 
rise to catarrhal stomatitis. Again, as one of the first or second 
molars advances, the mucous membrane of the gum directly over 
the tooth breaks down and a circular ulcer is formed. This ulcer 
possesses all the characteristics of the marginal ulcer of ulcerative 
stomatitis, and is very liable, provided such favoring conditions 
as scrofula, overcrowding and bad hygiene exist — to run around 
the alveolar border, and extend to the inside of the cheek. A 
case has recently been under my care, in which all of the six- 
year molars were cut in this way, the resulting ulcerative stoma- 
titis producing considerable discomfort, but yielding readily to 
treatment. 

Superficial ulcers upon the edges and tip of the tongue are 
often encountered. These ulcers correspond in position and 
number to loosened and perhaps decaying deciduous teeth ; are 
due to constant irritation of the mucous membrane ; are the seat 
of moderate pain, and more or less interfere with the movements 
of the organ in mastication and speech. They vary in shape 
and size but are generally oval, with the greater diameter — rarely 
more than half an inch — extending in the direction of the axis 
of the tongue. Their bases are smooth, red and shining, and 
their edges red, indented, somewhat indurated and surrounded 
by a narrow band of white fur formed upon the neighboring 
healthy epithelium. 

A boy, ten years old, was recently brought to consult me about 
the condition of his tongue. Nearly two months before the an- 
terior deciduous molars had commenced to loosen. Soon after 
two ulcers appeared upon the tongue at points corresponding to 
the loose teeth in the lower jaw. These caused considerable dis- 
comfort and interfered with the movements of his tongue. Six 
weeks later the four loose teeth were extracted. At the time 
of his visit the points of the permanent teeth were distinctly 
visible. The ulcers, which presented the characteristics already 
described, were present, too, but they were much contracted and 
evidently in process of healing. This case is a clear illustration 



172 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

of the etiology of the condition, and of the rapid effect of the 
removal of the cause. 

Loss, or perversion of taste, depending upon reflected irritation 
of the gustatory and glosso-pharyngeal nerves, has occasionally 
arisen in my experience. It is a feature that may be readily 
overlooked in childhood, and without doubt has never received 
due credit as a cause of the anorexia so often observed during 
second dentition. 

Of throat affections, simple hypertrophy of the tonsils and fol- 
licular tonsillitis seem particularly apt to arise in late childhood. 
The extension of catarrhal inflammation from the mouth to the 
throat is certainly an element in the causation of the conditions, 
though anorexia, imperfect digestion and fever are more potent, 
as they lead to impaired nutrition and increased susceptibility to 
the action of cold and bad hygienic surroundings. 

The treatment of this class of affections must vary with the 
symptoms presented. Should there be much inflammation and 
pain about a loose tooth, great relief can be obtained by painting 
the gum three or four times daily with a solution of — 

1J . Cocaine Hydrochlorate, gr. iv. 

Glycerinae, f ^ ij. 

Aquae, q. s., ad f^j. 

M. 
S. — For local use. 

When the first or second molars cause the trouble, free lancing 
with an oblique crucial incision is to be recommended. Much 
good can also be done in the way of softening the gums and 
lessening pain by a thorough application of — 

R. Zinci Chloridi, gr. j. 

Vin. Opii, f gj. 

Glycerinae, f^ij. 

Aquae Rosae, ........ q. s. ad fgj. 

M. 
S.— Apply to tender gums with a brush or soft cloth thrice daily. 

Such measures, too, will be more successful in relieving referred 
pains than any direct application to the place of reference. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 73 

Catarrhal and ulcerative stomatitis demand the usual methods 
of treatment. 

Superficial ulcers on the tongue can often be healed by a daily 
application of a solution of nitrate of silver (ten grains to one 
fluidounce) and the frequent use of a borax or chlorate of potas- 
sium wash (fifteen grains of either to one fluidounce). Should 
there be much pain and discomfort, the solution of cocaine 
recommended above may be used two or three times daily. 
When the deciduous teeth are decayed, however, nothing short 
of their extraction will cure the ulceration. 

Nothing can be done for loss or perversion of taste except 
removing loose teeth and freely lancing the gum over advancing 
molars. 

Hypertrophy of the tonsils and follicular tonsillitis must be 
treated in the same way as when they occur independently of 
dentition, the question of the propriety of extraction and of 
lancing being always borne in mind. 

(<£) After safely passing through primary dentition children 
usually grow robust and enjoy good health, unless they be 
attacked by some one of the acute contagious diseases to which 
their age is liable. This state of affairs may happily endure 
throughout the remainder of childhood, but it is often sup- 
planted, during the sixth and following years, by a condition 
best described as one of " general debility." 

This ill-health is neither produced by disease of important 
viscera, as of the lungs, heart, kidneys and digestive organs, nor 
can bad hygiene be blamed in many cases. For the explanation 
one must look rather to an impairment of nutrition, resulting 
from the constitutional strain of cutting the second teeth, from 
the moderate fever associated with the process, and from the 
diminished consumption of food, attending oral discomfort and 
painful mastication. The severity of the symptoms depends 
somewhat upon the general vigor of the subject, though in my 
experience it bears little or no relation to the difficulty or ease 
of cutting the milk teeth. 

Early in the sixth year, children so affected begin to lose 



174 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

their rosy cheeks ; the lips grow pale ; the skin of the body 
becomes sallow and harsh \ the hair dry and lustreless, and there 
is moderate loss of flesh with flabbiness of the muscles. The 
face wears an anxious expression and the temper is unstable ; 
by day frequent complaints of weariness are made and little 
interest is taken in play, while at night sleep is restless and there 
is often slight fever, with a temperature rarely above ioo° F. 
Pain and discomfort in the mouth are constant symptoms, and 
as these are increased by mastication, there is apparent anorexia. 
Examination of the mouth reveals redness, swelling and tender- 
ness of the gums over advancing molars, or if these have been 
cut, around loose temporary teeth. The bowels are inclined to 
constipation and the urine limpid and voided in abundant quan- 
tity ; the pulse is rather feeble though normal in frequency, and, 
as a rule, there is no cough nor other alteration in the respiratory 
function. Careful investigation shows an absence of lesion in 
the heart, lungs or kidneys, and of disease of the abdominal 
glands or digestive tract. As the teeth of the advancing group 
are cut, the symptoms disappear, to return with the approach of 
each succeeding group, but the anterior molars generally give rise 
to more marked disturbance than any of the teeth thaj; replace 
the temporary set. 

In addition to the ordinary risk of intercurrent disease exist- 
ing in every case of general debility, the condition just described 
is very apt to be complicated by bronchitis or catarrh of the 
gastro- intestinal canal. Pyrexia, although it is comparatively 
slight in second dentition, accounts for this, for a feverish child 
is very susceptible to cold, and very liable to have his digestion 
disordered by food upon which he has previously thriven. The 
first cause, by driving the blood from the surface, produces 
bronchitis; the second, by direct and indirect irritation, leads to 
catarrh of the mucous membrane of the stomach and bowels. 

This knowledge taken in connection with the course and his- 
tory of the case and the condition of the mouth, should enable 
the observer to attribute the illness to its proper source rather 
than to any complicating affection, although the latter undoubt- 



AFFECTIONS OF THE MOUTH AND THROAT. 1 75 

edly accentuates the symptoms, and may force itself into promi- 
nence. The negative results of physical exploration of the heart, 
lungs, and abdominal organs, — particularly the mesenteric 
glands — and of examination of the urine, are also important in 
establishing the correct relations of cause and effect. 

Careful regulation of the diet and the administration of tonics, 
the methods of treatment that would naturally be suggested, are 
of little avail, unless oral pain and difficulty of mastication be 
relieved. Even then, it is often impossible to do more than 
maintain a moderate degree of health until advancing teeth are 
completely free. 

Free lancing of the gums over molars, the application of 
cocaine to painful gums surrounding loose temporary teeth ; the 
extraction of these when the substituting teeth are so advanced 
as to run no risk of impairing the arch of the jaw : regulation of 
the diet and hygiene, aud the employment of tonics and laxa- 
tives are the measures to be recommended. The diet must be 
simple, non-farinaceous and nutritious ) it is better to allow four 
small meals a day than three large ones. Of tonics a good for- 
mula is : — 

R . Tr. Nucis Vomicae, TT^xij. 

Elix. Cinchon. Ferrat , f^ v j* 

Syrupi, f§ ss - 

Aquae, q. s. ad f5iij. 

M. 

S. — Two teaspoonfuls thrice daily at the age of six years. 

Syrup of the iodide of iron, bitter wine of iron and an emulsion 
of cod-liver oil with lacto-phosphate of lime, are also very use- 
ful. The best laxatives are fluid extract of senna, which may be 
combined with the tonic mixtures ; tincture of aloes and myrrh 
in small doses three times daily, compound licorice powder, 
glycerine suppositories or laxative tamarinds.* 

Complicating bronchitis and catarrh of the gastro-intestinal 
canal demand active attention, and little else can be accomplished 
until they are relieved. 

* See Habitual Constipation. 



176 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

(V) Disorders of the digestive system, while unattended by 
such marked symptoms and rarely reaching the same degree of 
danger as in primary dentition, are among the most common of 
disturbances produced by the eruption of the second teeth. 
One cause of this is the intimate sympathy existing between the 
different portions of the digestive tract, and leading to reflec- 
tion of irritation from point to point. Another and more active 
cause has already been indicated. It involves two conditions. 
First, general depression of vitality — from constitutional strain, 
fever, and so on — with a corresponding weakening of the func- 
tion of digestion, so that food previously suitable and easily 
assimilated, becomes relatively too coarse and "strong," and 
being more or less imperfectly changed and absorbed, lies in the 
alimentary canal undergoing fermentation and decomposition 
with the formation of irritant acids and gases. Second, the well- 
recognized susceptibility of the gastro-intestinal mucous mem- 
brane to become inflamed, or to assume the catarrhal state, when 
subjected to the action of irritants. A susceptibility decided 
enough under the best of circumstances, but intensely marked 
if the general health and resisting power be below par. 

Anorexia, vomiting, acute gastric catarrh, chronic gastro- 
intestinal catarrh, and diarrhoea are the more common of the 
digestive disorders attending second dentition. Loss of appe- 
tite when not due to perversion of taste, generally forms but one 
member of a group of symptoms depending upon catarrh of the 
stomach, and can be best studied under this head. The same 
may be said of vomiting. Of each of these symptoms it is also 
true, that they may be so prominent as to mask the associated 
features unless the observer be very careful. 

Acute gastric catarrh,* in so far as it is related to second denti- 
tion, is most frequently encountered during the eruption of the 
six-year molars. The attack of so-called "biliousness" and 
" indigestion " may or may not be preceded by some indiscre- 
tion in diet. 

* For description of this affection and its treatment see page 199. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 77 

It will fully repay the physician to inspect the mouth of every 
six-year old patient (and upward) suffering from acute indiges- 
tion, and after making the examination thoroughly to lance 
swollen gums over advancing molars, and apply soothing lotions 
to irritated gums about loosened temporary teeth, or order ex- 
traction if admissible. General treatment must be conducted on 
the same plan as when the attacks, as is often the case, occur 
independently of dentition. 

Chronic gastro-intestinal catarrh owes its origin to second 
dentition more frequently than to any other cause save whoop- 
ing-cough. In this condition — so aptly termed by Eustace 
Smith, "Mucous Diseases'' * — there is a mucous flux from the 
whole internal surface of the alimentary canal, which mechanic- 
ally interferes with the digestion and absorption of food and 
greatly impedes nutrition. It may be met with at any time dur- 
ing the eruption of the permanent teeth. 

Diarrhoea is a very constant attendant upon second dentition. 
It is most apt to arise in the changeable weather of spring and 
autumn or in the heat of July, August or September. In this 
respect it resembles the diarrhoea so common with primary den- 
tition, but unlike the latter, it shows little or no tendency to run 
into entero-colitis. Two forms are met with, namely catarrhal 
diarrhoea, and lientery.f 

The general depression produced by the coming of the second 
teeth, would naturally favor the development of any constitu- 
tional tendency, and, having traced the connection in several 
instances, I have no doubt that not a few cases of tubercular 
ulceration of the bowels owe something to this etiological factor. 

(d) Enlargement of the sub-maxillary gland, or one or more of 
the lymphatic glands of the neck, is a frequent occurrence during 
the approach of the first molars. Patients so affected may at the 
same time present other evidences of difficult dentition ; for 
example, they often show the symptoms of "general debility" 

* For description of this condition and its treatment see Mucous Diseases. 
f See Catarrhal Diarrhoea. 

is 



I 78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

already referred to, and often have mucous disease ; but they are 
quite as frequently perfectly healthy in constitution as strumous. 

The swelling of the gland or glands is moderate in degree ; 
there is considerable hardness, moderate tenderness and pain, 
but the superimposed skin is movable and healthy. There is 
some tendency to chronic enlargement and induration, though 
little or none to suppuration, save in scrofulous subjects. 

Should the gums be thoroughly lanced — and it is often neces- 
sary to sink the knife blade deep, to free the coming tooth — the 
glandular swelling soon subsides, though resolution can be has- 
tened by painting with tincture of iodine, or using the following 
ointment : — 

R. Ichthyol 55 j- 

Lanoline ^j. 

M. 
S. — Apply to the enlarged glands three times daily, with rubbing. 

(e and /) Conjunctival blennorrhoea and otitis, sometimes 
noticed during primary dentition, have come within my observa- 
tion, and, from the intimate connection between the nerves of 
the ear and eye and those of the teeth, it is more than probable 
that certain other disturbances of these two organs of special 
sense arise during second dentition, and depend upon dental 
irritation. Unfortunately so few cases of disease of these two 
organs come under my notice, and so little attention has been 
paid to this causal relation by specialists, that I have no data 
upon which to base conclusions. 

(g) Herpes of the lips, eczema, and urticaria frequently appear 
during the eruption of the second teeth. They apparently 
depend upon gastro-intestinal disturbances and are relieved by 
measures directed to the cure of disorders of this tract, together 
with appropriate local treatment, and attention to the teeth and 
gums. 

(k) Nasal catarrh, " teething cough," and an increased suscep- 
tibility to catarrh of the bronchial mucous membrane are the 
chief affections of the respiratory tract. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 79 

Nasal catarrh is generally sub-acute in type, and is attended by 
hypertrophy and redness of the Schneiderian membrane. There 
is a more or less copious discharge, which has a slight, heavy 
odor, may be composed of thin mucus or muco-pus, and which 
sometimes dries into thick crusts. This catarrh occasionally 
runs into ozsena in weak and strumous children. 

Attention to the teeth, frequent syringing of the nostrils, with 
insufflation of boracic acid and bismuth (i part to 2), the occa- 
sional application of a weak solution of nitrate of silver (gr. v- 
fSj), judicious use of the electro-cautery, and the administration 
of tonics, constitute the best treatment for the ordinary form of 
catarrh. Ozaena calls for its special plan of management. 
" Teething cough' ' is due to reflex irritation of the pneumo- 
gastric nerve ; it is identical with the " stomach cough" of mucous 
disease. 

Bronchitis can never be said to be due directly to dentition. 
This cause acts only indirectly by reducing general vitality and 
the power of resisting disease, and thus rendering the delicate 
bronchial mucous membrane more than ordinarly susceptible to 
catarrhal inflammation from chilling of the surface and exposure 
to damp air. An attack of bronchitis may occur with the 
eruption of one group of permanent teeth, or the attack may be 
repeated with several successive sets. 

I have in my mind now, the case of a delicate boy who, in 
spite of the utmost care on the part of his mother, had a most 
severe bronchitis during the eruption of the six-year molars, and 
a second persistent attack while the four central incisors were 
pushing their way through. Not two months before writing 
this, he again came under my care suffering from a third attack 
that promised equal obstinacy. On inspecting the mouth the 
four lateral temporary incisors were found to be quite loose and 
their permanent substitutes evidently advancing rapidly. Ex- 
traction of the loose teeth was ordered, together with a mild 
expectorant and a tonic mixture, and the catarrh soon subsided. 

(/) Nervous disorders, both sensory and motor are encountered. 

Headache is common. The pain is usually temporal and 



l8o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

unilateral. It may be seated however, in the occipital region or 
in different parts of the face, and sometimes shifts suddenly from 
the temporal to the occipital region. It is lancinating, more or 
less constant, with no distinct intermissions, and during its con- 
tinuance there is restlessness, anorexia, a frequent, hard pulse, 
sweating, dilatation of the pupil on the affected side, and perhaps 
dimness of vision, diplopia and colored or uncolored spectra. 
One or more painful points can often be detected, and generally 
there is a hard, tender, moderately enlarged lymphatic gland in 
the submaxillary or cervical region. 

These attacks are due to disordered vasomotor innervation, 
depending upon irritation of the sympathetic nerves and produc- 
ing irregular contraction or spasm of the vessels — the temporal or 
occipital artery, as the case may be. The real source of irritation 
is to be found in the mouth. The mode of action may be twofold. 
First, from a swollen gum or carious tooth the lymphatic vessels 
readily convey irritating matter to a neighboring lymph gland, 
and the irritation here excited acts, in its turn, as a disturber of 
the sympathetic nerves which furnish the vaso-motor supply to 
the carotid artery and its branches. This theory of the produc- 
tion of migraine has the value of the support of T. Lauder 
Brunton. 

The other method of production — and this I simply submit 
for consideration — is one of direct nervous connection; the 
submaxillary ganglion acting in the case of the lower teeth and 
the spheno-palatine in the upper, as the medium of transfer of 
irritation to the vaso-motor nerves. 

Bromo- caffeine, gelsemium, saline laxatives and tonics may be 
employed to lessen the severity of the pain, but lancing or ex- 
traction are the only certain remedial measures. 

The motor disturbances, while not quite so common as the 
sensory, are more varied. 

Reflex spasm and paralysis of the eyelid have been noted.* 
The former I have frequently seen, but the latter, so far as I can 

* Brunton. 



AFFECTIONS OF THE MOUTH AND THROAT. l8l 

recall, has never fallen within my experience. For the reflex 
spasms no method of treatment availed until the dental irritation 
was removed ; and the same statement maybe hazarded, a priori, 
in regard to paralysis of the lid. 

More extended paralysis also occurs. In this connection I can 
do no better than quote the words of Brunton, the correctness of 
which I can fully confirm. After speaking of paralysis of the 
eyelid this author states: — "Sometimes, however, paralysis oc- 
curs of a much more extensive character, in consequence of dental 
irritation, especially in children. Teething is recognized by 
Romberg and Henoch * as a frequent cause of paralysis appearing 
in children without any apparent cause. According to Fliess,f 
paralysis of this sort occurs more commonly during the period of 
the second dentition, whereas convulsions generally occur during 
the first. Its onset is sudden. The child is apparently in good 
health, but at night it sleeps restlessly, and is a little feverish. 
Next morning the arm, or more rarely, the leg, is paralyzed. 
The arm drops ; it is warm but swollen, and of a reddish-blue 
color. It is quite immovable, but the child suffers little or no 
pain. Not infrequently paralysis is preceded by choreic move- 
ments. Sometimes recovery is rapid, but at other times the limb 
atrophies, and the paralysis may become associated with symp- 
toms indicating more extensive disturbance of the spinal cord 
and brain, such as difficulty of breathing, asthma, palpitation, 
distortion of the face, and squint, ending in coma and death. 

"It is only in very rare instances that we are able to gain any 
insight into the pathological anatomy of such cases, because they 
rarely prove fatal, and even when they do so the secondary 
changes are generally so considerable as to leave one in doubt as 
to the exact mode of commencement. This renders all the more 
valuable the case recorded by Fliess, in which a boy five years 
old, and apparently quite healthy, found his left arm completely 
paralyzed on awaking one morning after a restless night. The 
arm was red, but the boy suffered no pain, and played about 

* Klinische Wahrnehmungen und Beobachtungen. 

f Fliess, Journ. der Kinderkr., 1849, J u ly an( l August. 



1 82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

without paying much attention to the arm. The same day he 
fell from a wagon upon his head, and died in a few hours. Apart 
from the fracture of the skull which caused his death, the ana- 
tomical appearances which were found were congestion of the 
spinal cord, and great reddening and congestion of the meninges 
near the point of origin of the brachial nerves, where the veins 
were also much fuller than on the corresponding right side. 
There was no organic change perceptible, either in the spinal 
cord or in the brachial nerves. On the other hand, the tumes- 
cence of the veins extended from the shoulder and neck up to 
the face, and was very striking in the sub-maxillary region. 

" This vascular congestion seems to point to vaso-motor dis- 
turbance of a somewhat similar kind to that which we have 
already noticed in connection with occipital headache, or with 
migraine accompanied by subjective appearances of either form 
or color." * 

This form of paralysis certainly suggests acute anterior polio- 
myelitis, though the symptoms are not quite identical and the 
age is not that at which " infantile palsy " usually occurs. 

Unfortunately, in all but the mildest cases, which get well 
quickly, when the paralysis appears the mischief is done and 
little benefit can be expected from attention to the teeth. The 
treatment must be conducted on the plan usually adopted in 
infantile paralysis. 

As just stated dental irritation sometimes produces choreic 
movements as prodromata of paralysis, but it much oftener acts 
as the exciting cause of genuine chorea in nervous children. 
Approaching molars, or carious, loose milk teeth about to be shed, 
may be the source of irritation. The causal relation is proved 
by the fact that the chorea disappears or yields quickly to ordin- 
ary treatment when the new teeth pierce the gums or are freed 
by lancing, or when decaying teeth are removed. Epilepsy is 
another nervous affection which can occasionally be traced to 
the same source. In such cases one usually finds a history of 
repeated general convulsions during primary dentition. 

* Brunton. " Disorders of Digestion," p. 93. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 83 

7. SIMPLE PHARYNGITIS. 

Catarrh of the mucous membrane covering the soft palate, 
tonsils and pharynx — simple or erythematous pharyngitis — is a 
common occurrence in children who have reached the third or 
fourth year, though it is rarely met with before that age. It may 
either be primary or secondary in origin. 

The Anatomical Lesion is hyperaemia of the affected mucous 
membrane. This is red, swollen, softened, granular, and at 
times oedematous. 

Etiology. — The primary form is most prevalent during the 
winter and spring. Impaired health, from neglect, bad food, or 
insufficient clothing predispose to an attack; while sudden 
changes in temperature and exposure to wet and cold are the 
chief excitants. One attack is often followed by others. The 
disease is not contagious, but many cases often occur simul- 
taneously. Secondary pharyngitis, which will not be studied 
here, constantly accompanies scarlet fever and measles, and 
often complicates bronchitis and pneumonia. 

Symptoms. — An attack of simple pharyngitis of ordinary 
gravity begins with fretfulness and lassitude; the child refuses 
food, and may vomit once or twice. Fever quickly follows, 
preceded by rigors, or in children nearing the age of puberty, 
by a single distinct chill. This fever is quite out of proportion 
to the local symptoms. The temperature in the course of a few 
hours rises to 102 or 104 F., and often higher; the pulse runs 
up to 130 or 140 beats per minute; the respiration is corre- 
spondingly rapid, though easy, the face is flushed and the skin 
dry. The voice becomes thick and husky, and there is a teas- 
ing, unproductive, hoarse cough, which may assume a brazen 
character toward evening. Older patients may complain of 
dryness and fulness of the throat, of a sensation leading to 
frequent efforts at deglutition, or of difficulty and pain in swal- 
lowing food ; while infants manifest the latter conditions by 
refusing the breast or bottle. An entire absence of these sub- 
jective symptoms, however, is common. 



1 84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

On inspection, the mucous surface of the soft palate, uvula, 
tonsils and pharynx presents a reddened, tumefied, dry, granular 
appearance, and may be partially covered with flakes of whitish 
mucus or muco-pus. The tonsils are somewhat swollen, and at 
times the uvula is oedematous. The lymph glands about the 
angles of the jaw are slightly enlarged and tender to the touch. 

On the second day the fever abates, the temperature often 
falling to the normal line, but there is an elevation on each suc- 
ceeding evening until the end of the fourth or fifth day, when 
the attack begins to subside. In the meantime the local symp- 
toms increase. Throughout, the child is peevish and restless, 
sleep is disturbed, the tongue is heavily coated, and there is loss 
of appetite, increased thirst, and a tendency to constipation. 

In exceptional cases the disease is much more grave in type. 
These severe attacks begin with vomiting, excessive restlessness 
or drowsiness, occasionally convulsions, and always high fever, 
with a temperature reaching 106 or even more, and a rapid and 
bounding pulse. The affected mucous membrane becomes in- 
tensely red and covered with a muco-purulent secretion. All the 
ordinary symptoms are intensified, and in addition there may 
be mild delirium and a flushing of the entire cutaneous surface, 
suggesting the scarlatinal rash. These attacks vary in duration 
from three to eight days, and, notwithstanding the alarming 
character of the symptoms, usually terminate in recovery. 

Diagnosis. — It is quite possible to overlook the presence of 
pharyngitis on account of the frequent absence of symptoms 
calling attention to the throat. Thus the sudden onset of high 
fever with rapid pulse and respiration and dry cough would, in 
the absence of difficult deglutition and pain in the throat, suggest 
an attack of croupous pneumonia. If, under the same condi- 
tions, the pharyngitis be ushered in by vomiting, the fever might 
readily be referrred to a digestive disorder. Such errors are to 
be avoided only by making a rule to inspect carefully the throat 
in each doubtful case. A grave case, again, may in the begin- 
ning be taken for one of scarlet fever, the resemblance being 
increased by the uniform flushing of the surface. Distinction is 



AFFECTIONS OF THE MOUTH AND THROAT. 1 85 

to be found in the different course of the two diseases, and the 
non-appearance of certain characteristic symptoms of the ex- 
anthem. 

Care must be taken not to confound the white or yellowish- 
white patches of mucus or muco-pus adhering to the inflamed 
surface with diphtheritic membrane. The former can be wiped 
away easily, leaving the mucous membrane intact. 

Treatment. — If the case be seen on the first day, it is possible 
greatly to reduce the severity of the attack by giving the child a 
hot mustard foot-bath,* putting him to bed in a properly-warmed 
room, and by cautiously administering aconite, with some saline 
laxative, as a small teaspoonful of magnesia in a wineglassful of 
strong lemonade. Under such circumstances, tincture of aconite 
root may be given to a child of four years, in doses of a drop 
every fifteen minutes until four drops have been taken, and sub- 
sequently the same dose every hour until an effect is produced on 
the pulse, or the heat and dryness of the skin are lessened. 

When the fever has been reduced in this way, or should the 
case not be seen until the second day, the following may be 
ordered : — 

R. Potassii Chloratis, gr. xlviij. 

Syrupi, , . . . f § ss. 

Aquae, q. s. ad f^iij. 

M. 

S. — One teaspoonful every three hours, in water, for a child 
of four years. 

If the fever returns as evening approaches, this mixture should 
be discontinued, and another foot-bath and a few doses of aconite 
given ; or some simple diaphoretic may prove sufficient, as liquor 
potassii citratis, at intervals of an hour during the night. 

Throughout the attack the diet should consist of milk and 
farinaceous articles prepared with milk, with a little meat broth 
as the fever subsides. A daily evacuation of the bowels must be 
secured, and the child must be kept in bed. 

* The ordinary strength of such a bath for a child of three or four years is 
one tablespoonful of mustard-flour to two gallons of water. 
16 



1 86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Local treatment must not be neglected. If the child be able, 
he should gargle the throat every hour with a solution of chlorate 
of potassium, ten grains to the fluidounce. If too young to do 
this, the same solution should be applied to the throat at short 
intervals with a mop of absorbent cotton. Painting the throat 
daily with a solution of nitrate of silver (gr. v to fgj) hastens the 
cure. At the same time it is well to redden the skin of the neck 
with some such liniment as : — 

R. 01. Terebinthinse, fgj. 

Ol. Olivse, fgiij. 

M. 
S. — Apply twice daily. 

Grave cases require no alteration of this plan. It is well, if 
there be great restlessness, to repeat the foot-bath, or even to give 
several full warm baths of ten minutes' duration. If there be 
intense inflammation of the pharynx the neck should be envel- 
oped in a poultice, or in extreme cases a leech may be applied 
behind each angle of the lower jaw. Clogging of the throat by 
tenacious mucus demands an emetic. 

When convalescence begins, the diet must be more liberal, 
and restoration to perfect health is hastened by administering a 
bitter tonic, as tincture of nux vomica, or compound tincture of 
gentian, in appropriate doses, three times daily. 



8. SUPERFICIAL CATARRH OF THE TONSILS. 

In this affection there is a simple hypersemia of the mucous 
membrane covering the tonsils, accompanied by moderate swel- 
ling of the glands. It is produced by the same causes, and 
usually occurs as an element, merely, of general pharyngitis. In 
the exceptional cases in which it exists in an isolated form, the 
tonsils will be found reddened and moderately swollen, and 
several yellowish-white points, due to retained follicular secretion, 
will be seen on their surfaces. The local subjective, and the 
general symptoms are the same as those of pharyngitis, and they 
yield to the same measures of treatment. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 87 

9. FOLLICULAR TONSILLITIS. 

In this disease there is, in addition to superficial hyperaemia, a 
catarrh of the lacunae or follicles of the tonsils. According to 
the extent of the disease, several or all of the follicles become 
filled with a yellowish-white, curd-like material, consisting of 
epithelium and pus. When thin, this flows away ; but, when 
thick, it is removed with difficulty, collects and distends the 
lacunae, and may undergo desiccation, or even become calcified. 
The parenchyma of the tonsils becomes hyperaemic, and there is 
an infiltration of serum and a proliferation of the gland cells. 

Etiology. — The affection is a common one after the fifth year. 
It is most apt to be met with in the winter and spring, but it 
may occur at any season. Exposure to wet and cold is usually 
considered to be the exciting cause, but an attack may quite as 
frequently be traced to over-eating, associated with excitement 
and fatigue. One attack predisposes to others, and I have seen 
many patients who are invariably affected after gorging them- 
selves with rich food, pastry or candy. A combination of all of 
these causes — so well afforded by that worst of institutions, a 
child's party — invariably produces a crop of cases. 

Symptoms. — When due to over-eating, the attack usually sets in 
on the day succeeding the indulgence. It begins with headache, 
lassitude, pain in the back and legs, and more or less rigor. 
The tongue becomes frosted ; there is thirst, anorexia and nausea, 
often followed by vomiting. Toward the evening of the first 
day the face becomes flushed, the skin hot and dry, and the pulse 
rapid. The bowels are sluggish, and the urine is scanty, high 
colored, and lateritious. On the morning of the second day the 
fever abates, but it returns in the afternoon, and this course is 
maintained for three or four days, when convalescence is estab- 
lished. In the meantime the anorexia and constipation continue, 
the patient sleeps badly ; may even be slightly delirious at night, 
and, finally, is left so feeble that health is not restored for a week 
or more. 

When the affection is due to exposure alone, there is less head- 



1 88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ache, and no nausea or vomiting. In other respects the course 
is similar, though the attack is followed by less prostration. 

Whatever the cause, the local symptoms are the same. They 
consist of a sensation of dryness and heat in the throat, repeated 
efforts to clear the throat, difficult and painful deglutition, in- 
creased salivation, a nasal intonation of the voice, and a heavy, 
offensive breath. On inspection, a catarrhal condition of the 
palatine arches and pharynx is observed. The tonsils are en- 
larged, sometimes sufficiently so as almost to meet one another ; 
their enveloping mucous membrane is reddened and swollen, and 
their surface is dotted with yellowish-white points, corresponding 
in number, shape and size with the follicles involved. These 
points are sometimes covered and concealed by muco-pus, and 
may be surrounded by shallow, circular erosions of the mucous 
membrane. On pressing the tonsils, ill-smelling masses of vary- 
ing size and consistency may be pressed out. These are also ex- 
pelled by hawking,/)r are forced out in deglutition and swallowed 
with the food. In whichever way removed, they leave the orifices 
of the follicles more widely open and gaping than in health. 
There is some tenderness on pressure beneath and behind the 
angles of the jaw. 

The Diagnosis is easily made from the appearance of the 
tonsils, and from the fact that gentle pressure with the finger will 
force out one or more masses of retained secretion — a pathogno- 
monic sign. There is no doubt that these cases are by some 
classed as diphtheritic, though none but the most inexperienced 
could confound the numerous yellowish-white points, of irregular 
shape and size, depressed below or projecting beyond the well- 
defined lips of the follicles, and which, as already stated, can be 
often expelled by pressure on the tonsils, with diphtheritic mem- 
brane. Again, the difference between this affection and a patchy 
tonsillar diphtheria — a common enough disease — must strike any 
careful observer. 

The Prognosis is always favorable, except that one attack pre- 
disposes to others, which may lead to chronic hypertrophy of the 
tonsils. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 89 

Treatment. — If the attack be traced to over-eating, the ad- 
ministration of an emetic would naturally suggest itself as a pre- 
liminary. This, however, is rarely necessary, as the initial vom- 
iting empties the stomach sufficiently. Usually, the first steps 
are to place the child's feet in a hot mustard bath, then put him 
to bed, and give, according to the age, one or two grains of 
calomel at once, or in broken doses if there be much nausea. If, 
on the first night, the fever be high, tincture of aconite should 
be resorted to ; if more moderate, an effervescing draught, like 
the following, will suffice : — 

R. Acidi Citrici, ^jss 

Aquae, f g iij. 

M. 
S. — Solution No. 1. 

R. Potassii Bicarbonatis, jjj. 

Aquae, f* ^ iij . 

M. 
S. — Solution No. 2. 

A teaspoonful of each solution is to be poured into a tablespoon 
or glass and taken while effervescing. 

This draught has the advantage of checking nausea at the same 
time that it reduces fever. 

Small pieces of ice should be swallowed at short intervals to 
relieve thirst and lessen the inflammation of the tonsils, and the 
food must be restricted to small quantities of milk and lime- 
water (3 to 1), or weak broths in case milk disagrees. On the 
second day, it is only necessary to look carefully after the diet, 
to allow nothing but milk and broths ; keep the patient in bed, 
and give during the day the following: — 

R. Pulv. Pepsinae, 

Sodii Bicarbonatis, aa gj. 

M. et ft. chart. No. xij. 
S. — One powder every three hours for a child of six years. 

The effervescing mixture may still be used in the early night if 
the fever be high enough to require it. 

Such measures should be continued until convalescence is 



I90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

established, care being taken to keep the bowels regular with 
calomel in broken doses. Then the diet may be gradually in- 
creased and a bitter tonic given. 

If the cause be exposure to wet and cold, the general treatment 
must be the same as for pharyngitis. 

The local treatment embraces counter-irritation of the skin of 
the neck ; touching the tonsils once daily with a solution of 
nitrate of silver, gr. v to fgj ; and frequent gargling with :— 

R. Potassii Chloratis, gr.lxxx. 

Acid. Carbolici, , gr.ij. 

Glycerinse, fgj. 

Aquae, q. s. ad fg viij. 

M. 
S. — Use as a gargle every hour. 



10. SUPPURATIVE TONSILLITIS. 

Quinsy is a rare disease in childhood and is scarcely ever met 
with before the twelfth year. When it does occur, some family 
predisposition can generally be traced. One of the most com- 
mon predisposing elements is the rheumatic diathesis. Fatigue 
and exposure are the exciting causes. It is most frequent during 
spring and autumn. One attack predisposes to others. It may 
arise as a primary affection or as a complication of scarlatinous, 
variolous, or diphtheritic anginas. One or both tonsils may be 
affected. 

Morbid Anatomy. — At first there is intense hyperaemia with 
serous infiltration of the glandular tissue, and the tonsils some- 
times become swollen to more than double their size. The 
inflammation may now undergo resolution. Otherwise an in- 
filtration of small cells takes place, into and between the follicles, 
into the inter-lacunar connective tissue, and in the capsule. 
Retrogression is still possible, or failing this a new formation of 
reticulated substance takes place, resulting in permanent hyper- 
trophy; a frequent termination of repeated attacks in children. 
If the inflammation be very intense, an abscess forms, but 



AFFECTIONS OF THE MOUTH AND THROAT. I9I 

suppuration is not the usual result of tonsillitis occurring before 
puberty. With these conditions there is always associated 
general pharyngitis and often follicular tonsillitis. 

Symptoms. — The disease begins with rigors or a distinct chill, 
followed by sneezing, epistaxis, headache, pain along the Eus- 
tachian tube, loss of appetite, and fever, with languor and mus- 
cular prostration during the day, and mild delirium at night. 
Soon the*patient complains of dryness and burning in the throat, 
difficulty and pain in deglutition, and the voice becomes nasal. 
If the throat be inspected, the mucous membrane of the soft 
palate and pharynx is seen to be red and swollen, and one or 
both tonsils are reddened and enlarged, often presenting several 
whitish-yellow points of retained follicular secretion. If one 
tonsil only be affected, the cedematous uvula will be pushed to 
the opposite side — an important sign. 

The symptoms gradually increase in severity. The tempera- 
ture ranges from 99 or ioo° F., in the morning, to 102 or 
104 in the evening, and the pulse from no to 120; but the 
respiration, though snoring, is little increased in frequency. 
Pain and difficulty in deglutition grow worse ; the voice assumes 
a peculiar, thick, nasal tone; the breath has a heavy odor; the 
salivary secretion is increased and dribbles from the mouth ; the 
tongue is heavily furred, and the bowels are sluggish. The 
child's face wears an apathetic expression, is red or dusky in 
hue, and there is dulness of hearing. Talking is painful, and so 
also is any movement of the jaw. On this account it is difficult 
to obtain a view of the throat ; but if such be had, the tonsils, 
when both are affected, are seen to be intensely congested, and 
so much swollen that they meet ; or, when only one gland is in- 
volved, it often extends a third of an inch beyond the median 
line. The day is divided between the listless inaction of pros- 
tration and the uneasy tossing of discomfort, and the night, 
between the restlessness of fever and the wandering of delirium. 
What little sleep is obtained is interrupted by snoring. 

The crisis usually occurs on the fifth day, although it may be 
postponed until the eighth. If the tonsillitis ends in resolution 



192 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the fever rapidly subsides, disappearing entirely in twelve hours; 
the local symptoms simultaneously abate and convalescence is 
rapid. When the inflammation ends in the formation of new 
tissue and hypertrophy of the glands, the acute manifestations 
give place to a train of symptoms to be described in the next 
section. Finally, if suppuration take place, there is a chill 
followed by high fever. The abscess soon points toward the 
mucous surface of the gland, and, unless opened by lancing, is 
broken by an eifort at deglutition or in an examination of the 
throat. The quantity of pus discharged is ordinarily small, and 
is swallowed, as a rule. After the opening of the abscess, the 
child passes at once from a condition of great distress to one of 
comparative comfort, and strength and health are soon regained. 

The Diagnosis of quinsy is unattended with difficulty, and 
the prognosis, so far as life is concerned, is always good, 
though the danger of chronic hypertrophy must not be forgotten. 

Treatment. — If the patient can be seen when the peculiar 
tone of the voice, the pain in the line of the Eustachian tubes, 
and the deflection of the uvula indicate the beginning of tonsil- 
litis, it is possible to abort, or, at least, greatly reduce the inten- 
sity of the inflammation. For this purpose he must be put to 
bed, and given a sufficient quantity of wine of ipecacuanha to 
empty the stomach. Then properly proportioned doses of tinc- 
ture of aconite root must be administered every half hour until 
an effect is produced on the temperature and pulse, and small 
bits of ice must be swallowed at intervals of ten minutes. At 
the same time it is well to apply a sinapism to the side of the neck 
corresponding to the affected gland. Since the introduction of 
cocaine I have often succeeded in aborting tonsillitis by thor- 
oughly mopping the affected parts three times daily with a four per 
cent, solution of this drug. Even in cases where this favorable 
result was not obtained, the cocaine so far allayed pain as to per- 
mit liquid food to be swallowed with ease. This is an invaluable 
aid in the treatment of severe quinsy occurring in feeble 
children. 

When the case is not seen till later, the indications are to 



AFFECTIONS OF THE MOUTH AND THROAT. 1 93 

encourage resolution or hasten suppuration, and to maintain the 
strength. To fulfil the first, the neck should be enveloped in a 
poultice, the throat should be repeatedly gargled with warm 
water, and steam from an atomizer should be constantly inhaled. 
The strength is to be kept up by administering all the concen- 
trated liquid food that it is possible for the patient to swallow 
and by using suppositories of quinine. The latter may be 
ordered in this way : — 

B . Quinioe Bi-sulphatis, gr. xij. 

Ol. Theobromae, rjiij. 

M. et ft. supposit. No. xij. 
S. — Use every four hours for a child six years of age. 

On account of the difficulty in swallowing it is well to avoid 
ordering any medicine by the mouth except a diaphoretic, such 
as the solution of the citrate of potassium, and an occasional 
dose of some saline laxative. When there is much restlessness 
or delirium at night, it is well to give bromide of potassium, in 
ten-grain doses, by the mouth or rectum. 

If an abscess forms, a somewhat rough pressure of the finger 
against the involved tonsil will hasten its rupture, but incision is 
a better method of treatment and often lessens the duration of 
suffering by twenty-four hours or more. 

After the crisis is past, the diet must be increased and a tonic 
ordered as: — 

R. Tr. Ferri Chloridi, f^j. 

Quinise Sulphatis, gr. xij. 

Syrupi Zingiberis, f^J* 

Aquae, q. s. adfjiij. 

M. 
S. — One teaspoonful, in water, three times daily for a child 
six years old. 

The subsidence of the tonsils to their normal size is hastened 
by painting them twice daily with — 

R. Acidi Tannici, ^j. 

Glycerinse, fgj. 

M. 



194 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

For prevention, gargles of cold water and astringents, appli- 
cations of the glycerole of tannin, and measures to maintain a 
high standard of health and counteract any rheumatic tendency, 
should be employed. 



ii. HYPERTROPHY OF THE TONSILS. 

Chronic enlargement of the tonsils is slow in its development, 
and must be considerable in degree before giving rise to definite 
symptoms. Consequently, the disease is rarely recognized before 
the third or fourth year of life, although its commencement in 
early infancy is quite possible. It is common between the seventh 
and twelfth years. 

Etiology. — Repeated tonsillar inflammation and the irritation 
attending dentition are the ordinary exciting causes, but it may 
appear spontaneously in children who are out of health, strumous 
or syphilitic. As the symptoms are aggravated by any passing- 
angina, more cases demand treatment during the winter and 
spring than at other seasons. 

Symptoms. — The first to attract attention is loud snoring during 
sleep, due to pressure upon the velum, and obstruction to the 
passage of air through the posterior nares. At the same time 
there is a decided nasal twang to the voice. Examination shows 
marked projection of both tonsils, or, more rarely, of one only ; 
the follicular orifices are widely open and very distinct, and 
several of them may present the yellowish-white points of retained 
secretion. The investing mucous membrane is pale, as a rule, 
but it may be traversed by arborescent blood vessels. Such a 
degree of hypertrophy and the accompanying symptoms some- 
times disappear spontaneously with the development of the 
mouth and vocal organs attendant upon puberty. 

When the glands are so much enlarged that they touch in the 
mid-line of the throat, there are added to the other symptoms a 
constant hacking cough with labored respiration, and difficulty 
of hearing, due partially to pressure upon the orifices of the 



AFFECTIONS OF THE MOUTH AND THROAT. 1 95 

Eustachian tubes, and partly to a state of habitual congestion 
kept up in the surrounding parts. The dyspnoea is much worse 
at night, and the little patient often starts from sleep in a state 
of terror. It may be so grave as to threaten life and necessitate 
tracheotomy. 

When enlargement — so great as to almost completely obstruct 
the passage of air through the nose — has existed from an early 
age, noticeable anatomical changes take place. The nostrils be- 
come extremely small and compressed, while the superior dental 
arch retains the narrowness of infancy, not allowing room for 
the teeth, which, in consequence, overlap one another. The 
palate, also, becomes unusually high and arched. Furthermore, 
the obstacle to the free entrance of air prevents the lungs being 
readily filled in inspiration, so that a partial vacuum is formed 
between them and the chest-wall, to fill which the external air- 
pressure forces in the yielding parietes. The effect of external 
pressure is most marked where the resistance is least, namely, at 
the base of the thorax, and a constant and long-continued repe- 
tition of this leads to the production of a gutter of variable depth 
and three or four inches in width, extending laterally from the 
lower part of the sternum, and to a projection forward of this 
bone. Any tendency to pulmonary phthisis is increased by this 
deformity, and if tubercular disease be present, the impediment 
to the entrance of air, and the constant irritation of the air pass- 
ages, maintain a condition most unfavorable to its arrest. 

Treatment. — Moderate enlargement of the tonsils in a weakly 
child will sometimes disappear when puberty is passed, or as 
health is regained under a course of tonics. The best tonic is 
syrup of the iodide of iron, in doses of ten drops three times 
daily for a child of eight years of age. It is well to paint the 
tonsils once every day with one of the following astringents : — 

&. Tr. Ferri Chloridi, f^j. 

Glycerinse, q. s. ad fgj. 

M. 

R . Liq. Iodinii Comp., f 3 ij. 

Glycerine, q. s. adfgj. 

M. 



196 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

• 

When there is marked hypertrophy, the best and most rapid 
results (next to excision) are obtained by the careful use of the 
electro-cautery. Children of six or eight years readily submit 
to this treatment provided thorough cocaine anaesthesia be pro- 
duced before each application of the heated wire. A gargle 
containing tannic acid must also be used four times daily, as : — 

R. Acidi Tannici, '. gss. 

Glycerinae, f§ ss - 

Aquae, q. s. ad f^viij. 

M. 

Syrup of the iodide of iron should be given three times daily, 
care being taken not to administer it at the time that the gargle 
is used. Cod-liver oil is also serviceable. 

Together with this treatment enough nutritious food must be 
given to keep up the strength. This can be done with readiness, 
since, in spite of the size of the tonsils, there is usually no pain, 
and little difficulty in swallowing. 

Excision must be practiced when there is excessive enlarge- 
ment, provided the above measures of reduction have been tho- 
roughly tested without avail, or if, at any time, there is dangerous 
interference with respiration. Constant or frequent cough, or the 
presence of any other symptom suggestive of phthisis, also 
demands an immediate operation. 

If, after removal of a portion of the tonsils or their reduction 
by treatment, the chest is slow to regain its natural form, the use 
of light dumb-bells and carefully regulated gymnastics are of 
much service. Dupuytren's method of reducing the sternal pro- 
minence by placing the child's back against a wall, and pressing 
it firmly backward with the palm of the hand during each act of 
expiration, is efficient, notwithstanding its apparent roughness. 



AFFECTIONS OF THE MOUTH AND THROAT. 1 97 

12. RETROPHARYNGEAL ABSCESS. 

Abscess behind the pharynx is an uncommon disease ; so rare 
is it, indeed, that in many years' experience at the Children's 
Hospital I have seen but one case, and this, unfortunately, passed 
from observation before its termination. 

Its occurrence is not limited to any age. It results from direct 
injury ; from disease of the cervical vertebrae ; as a sequel of 
fever ; or, more frequently, arises idiopathically. 

The symptoms are difficulty in swallowing and breathing, with 
a peculiar sound during the latter act. On lying down the res- 
piratory embarrassment is increased, sometimes to such an extent 
as to threaten suffocation. There is, also, great stiffness of the 
neck, retraction and immobility of the head, and a diffuse swell- 
ing of the lateral cervical surfaces, often greater on one side than 
the other. ' If now the finger be carried over the root of the 
tongue, and down toward the pharynx, a firm or fluctuating 
swelling will be felt, more or less filling the pharyngeal canal, and 
projecting over the opening of the glottis. On inspecting the 
throat, the swelling can usually be seen, occupying one or other 
side or the middle of the pharynx, and pressing forward the 
uvula and soft palate. The investing mucous membrane may be 
normal or congested. Sometimes the mouth cannot be suffi- 
ciently opened to permit of inspection, and at others the abscess 
is seated so low in the pharynx that no tumor can be seen. 

Duparcque enumerates three symptoms indicating the forma- 
tion of an abscess behind the oesophagus, viz.: Severe pain, pro- 
duced even by moderate pressure on the larynx and upper part 
of the trachea. The entire suspension of respiration by such 
pressure. Displacement of the larynx forward and to the right. 

Fever and cerebral manifestations may or may not be present, 
and initial symptoms are far from being uniform, so that, unless 
an examination of the throat be made, the disease may be over- 
looked in its early stages. Ordinarily, however, the diagnosis 
can be made without difficulty. 



I98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Dr. West, describing the lesions in one of his cases, states : 
" Immediately on dividing the cervical fascia on the right side, a 
quantity of thick, yellow, healthy pus passed out. This matter 
had burrowed close to the oesophagus, to within a little more than 
an inch of the clavicle, and also in an oblique direction behind 
the oesophagus toward the left side, completely detaching it from 
its connections on the right side, though not on the left. It 
passed up behind the oesophagus and pharynx quite to the base 
of the skull, a few threads of cellular tissue bathed in pus being 
all that remained of their posterior attachments. The tonsils 
were not enlarged, and the glottis was neither red nor swollen, 
but quite natural.' ' 

The prognosis is very grave when the disease accompanies 
cervical caries ; under other circumstances it is favorable. When 
untreated, the course is prolonged, as the abscess is slow to break 
spontaneously. Suffocation from the sudden discharge of pus is 
an exceptional event. 

The treatment is simple. As soon as the abscess has formed, 
it must, when within easy reach, be punctured by a bistoury, the 
blade of which has been carefully wrapped with adhesive plaster 
to within a fourth of an inch of its point. If the abscess be 
situated low down, a trocar and canula is the safer instrument to 
employ. 

For several days after the operation, occasional pressure must 
be made by the finger on the tumor, to ensure thorough evacua- 
tion of the pus. At the same time a general tonic and support- 
ing treatment is advisable. 



CHAPTER II. 

AFFECTIONS OF THE STOMACH AND 
INTESTINES. 

The fact that hyperemia is the acknowledged condition of 
the gastro-intestinal mucous membrane during digestion, and the 
easily appreciated readiness with which this hyperaemia may 
pass from a normal to an abnormal degree under the influence 
of such apparently trifling irritants as food in excessive quantity 
or of improper quality, has led me to doubt the existence of 
what is usually termed "simple indigestion " or "functional 
dyspepsia.' ' The doubt has been strengthened after years of 
special study of this class of affections in children, and I am now 
disposed to attribute all forms of disordered digestion to a 
distinct tissue lesion. This may be, and usually is, a simple 
catarrh ; but it is none the less a lesion. The fact of its leaving 
no traces after death, when this event has occurred from other 
causes, is a poor argument, for no one expects to be able to 
detect the lesions of simple pharyngitis, for instance, under like 
circumstances. 

In consequence of this belief, I have departed somewhat from 
the usual plan of classifying diseases of the digestive tract. 



i. ACUTE GASTRIC CATARRH. 

This is one of the most common ills of childhood, since, in 
addition to arising idiopathically, it attends every disease in which 
there is pyrexia, as well as many of those that are apyretic. 

The Idiopathic Form may occur at any age, but is infrequent 
in breast-fed infants. Its origin under such circumstances is 
always traceable to some abnormal condition of the mother's 
milk. The ordinary predisposing causes are dentition, general 

199 



200 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

feebleness of constitution, exposure, and imperfect hygiene. 
Exposure is also an excitant, but the chief of this class of causes 
is the administration of food that is either bad in quality or 
excessive in quantity. An attack, too, sometimes directly follows 
the use of emetic doses of antimony, sulphate of copper or ipe- 
cacuanha. 

The Anatomical Lesion is hyperaemia of the mucous mem- 
brane of the stomach, producing an increased secretion of mucus, 
and a diminished flow of gastric juice. 

Symptoms. — An attack of what the nurse calls (i indigestion M 
comes on in infants after a bottle of changed milk or a " taste " 
of some unusual food has been given ; in older children after a 
mixed and indigestible meal, particularly when this has been 
attended by exposure and excitement. The child, after a few 
hours, becomes listless, has a hot, dry skin, loses appetite, is 
thirsty, sleeps restlessly, and, if old enough, complains of head- 
ache, abdominal discomfort and nausea. Then there is vomiting 
of sour-smelling, curdled milk, : or of whatever food is in the 
stomach in a more or less imperfectly digested state. The first 
act of emesis is easy, but if repeated, as is often the case, there is 
painful retching, and nothing is expelled save a little bile-stained 
mucus. Soon the tongue becomes covered, except at the very 
tip and edges, which are red, with a thick white or yellowish- 
white fur, through which the fungiform papillae protrude as bright 
scarlet points. The breath has a heavy or sour odor. There is 
some fever, the temperature ranging from one to three degrees 
above normal, and the pulse counting no or 120 per minute. 
There is moderate tenderness on pressure in the epigastric region. 
The bowels are confined, and the urine is lessened in quantity 
and lateritious. These symptoms continue from twenty-four to 
forty-eight hours. 

The attack sometimes terminates suddenly, with several loose 
faecal evacuations. In other cases the fever gradually subsides, 
the nausea and thirst diminish, the tongue cleans, and the 
appetite slowly returns, convalescence extending over a period 
of two or three days. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 201 

The Diagnosis is readily established by the history of the 
causation, the character of the vomit, the state of the tongue, 
the moderate fever, the epigastric tenderness, and the course of 
the attack. 

The Prognosis is always favorable so far as recovery is con- 
cerned, but it must be remembered that one attack always in- 
creases the susceptibility to another. 

Treatment. — Complete rest, on the nurse's lap for infants, 
and in bed for older children, is essential. During the first 
twelve or twenty- four hours there is no inclination for food, and 
if any be forced it is quickly rejected. Consequently it is better 
to avoid any attempt at feeding until the stomach becomes 
settled. Thirst is to be relieved by ice, swallowed in small bits 
at short intervals, and by frequent small draughts of iced carbonic 
acid or Vichy water. Such measures are also useful to allay 
nausea and vomiting, but if these symptoms are at all obstinate, 
a mustard sinapism, just strong enough to redden the skin, should 
be applied to the epigastrium, and the following prescription 
ordered : — 

R . Liquor. Calcis, 

Aquae Cinnamomi, aa f § ij. 

M. 
S. — One to two teaspoon fuls, according to the age, at in- 
tervals of 15 to 30 minutes, as necessary. 

Frequently repeated small doses of the effervescing citrate of 
potassium, or of the effervescing draught already mentioned 
(page 189), are efficient. A good plan, too, is to divide the 
contents of both packages of a Seidlitz powder into a number of 
equal parts, about twelve for a child of three years; dissolve a 
portion from each in a small tablespoonful of water, pour them 
together, and administer in a state of effervescence. This may 
be repeated, at first, every half-hour, later at longer intervals : 
rarely more than six or eight doses are required to check the 
vomiting. This method has the additional advantage of acting 
gently on the bowels. 

In those exceptional cases in which, after an unsuitable meal, 

T7 



2Q2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

there is headache, fever, epigastric discomfort, and nausea with- 
out vomiting, it is necessary, as a preliminary measure, to induce 
emesis by draughts of warm water or a sufficient dose of syrup or 
wine of ipecacuanha. 

When vomiting has ceased and nausea disappeared, the patient 
must begin to take food. At first one ounce of sound milk 
diluted with half an ounce, or even an ounce, of lime-water or 
barley-water may be given every two hours ; and the quantity- 
increased and the dilution lessened as the stomach regains its 
functional powers. Weak mutton, veal, or chicken broth, free 
from grease, and diluted with one-half or an equal quantity of 
barley-water, sometimes suits when milk cannot be retained. 

While attention is paid to the diet, care must be taken to 
secure a free evacuation of the bowels by a mercurial followed by 
a saline laxative. Beyond this, all that is required is to admin- 
ister properly-proportioned doses of bicarbonate of sodium and 
pepsin before each meal, for three or four days, and to gradually 
increase the diet to its normal standard as healthy digestion is 
restored. 



2. CHRONIC GASTRIC CATARRH. 

This affection presents so many points of dissimilarity, accord- 
ing to the age of the patient, that it is desirable to study it under 
two heads, namely, chronic gastric catarrh in infants, and chronic 
gastric catarrh in children who have passed the period of first 
dentition. Further, since chronic catarrh of the stomach is 
always attended by imperfect gastric digestion, and since food 
imperfectly digested in the stomach is unfitted for intestinal 
digestion, and must act as an irritant and lead to intestinal 
catarrh, it is impossible to absolutely isolate the two conditions 
in a clinical description. This is so markedly the case in older 
children that it seems best to defer the study of the second divi- 
sion of the subject to a later section, headed " chronic gastro- 
intestinal catarrh," and at present to consider only — 



AFFECTIONS OF THE STOMACH AND INTESTINES. 203 

CHRONIC GASTRIC CATARRH IN INFANTS. 

This dangerous affection, sometimes termed "chronic vomit- 
ing," is of common occurrence. 

Morbid Anatomy. — In the earlier stages there is a simple 
hyperemia of the gastric mucosa, but a long continuance of this 
condition thickens and loosens the membrane, changes its color 
to an ashen-grey, and leads to an excessive formation of tenacious 
mucus or muco-pus, while greatly lessening the secretion of 
efficient gastric juice. Coincident enlargement of the gastric 
glands also gives the' appearance of roughness to the surface of 
the mucous membrane. 

Etiology. — The period of life between the third and seventh 
months furnishes by far the greatest number of cases. Sex and 
season are not influential. Infants fed entirely at the healthy 
breast are very rarely affected. 

The predisposing causes belong to the class of influences that 
lower the readily depressed vitality of early infancy ; for instance, 
over-crowding, filth, want of sun-light and fresh air in dwelling- 
rooms, insufficient clothing, and too early weaning. 

The one great exciting cause is the administration of unsuitable 
food. Sometimes the breast-milk departs so much from its normal 
quality that it acts as an irritant upon the delicate mucous mem- 
brance and produces catarrh ; or it may flow so freely that the 
child swallows more than he can digest, and the surplus, having 
undergone chemical change in the stomach, produces a like 
result. But the harm commonly arises from the use, in artificial 
feeding, of food that is either, by its nature, unsuited to the 
feeble digestive ability of infancy, or which, though good in 
itself, is rendered hurtful by being kept in unclean vessels, and 
given from foul or badly constructed bottles. 

Of the first or essentially bad articles of diet, the farinaceous 
foods are the most harmful, because, for the digestion of starch, 
both saliva and pancreatic juice are required, and these secretions 
are absent until the fourth month and not fully established for 
some time later. Further, when subjected to the action of a 



204 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ferment, as mucus, in the presence of heat and moisture — con- 
ditions existing in the stomach — these substances readily undergo 
fermentation resulting in the formation of acid which acts as an 
irritant to the susceptible mucous membrane. Consequently, 
such a diet used, as it too often is, to the exclusion of milk, 
must be a very active cause of gastric catarrh. The habit of allow- 
ing or encouraging infants to bolt bits of table-food and drink 
tea is quite as injurious; perhaps, though, this indiscretion is 
more apt to produce chronic diarrhoea than chronic vomiting. 

Perfectly pure milk will be quickly changed and rendered irri- 
tating and unfit for use by being poured, when delivered by the 
milk-man, into pitchers or cans not properly cleansed from the 
remains of the supply of the day before. The smallest quantity 
of sour milk is sufficient to rapidly produce a like change in 
several pints of the fresh fluid when mixed with it. The same is 
true of unclean bottles and tips to which the dregs of former meals 
adhere in the form of small white curds. In these the change 
begins as soon as the fresh milk is added, and advances far before 
the child finishes the meal. 

A knowledge of the etiological factors explains why by far the 
greatest sufferers are foundlings, foster-children, children born to 
poverty, and those belonging to women who engage themselves 
as wet-nurses, or are obliged to earn their living by working away 
from home. 

Symptoms. — The first symptom is vomiting, occurring at ir- 
regular intervals, and resulting in the expulsion of curdled, sour- 
smelling milk, or whatever food is in the stomach, stained yellow 
or green by bile. The characters of the vomit however, soon 
change, the bile disappearing and only a clear, watery fluid, con- 
taining fragments of food, being ejected. In addition, there 
are eructations of sour or even fetid gas. The surface of the 
body is normal in temperature or cool, the skin is harsh and sal- 
low, and an eruption of strophulus may cover the trunk and arms. 
The lips are red and dry, the tongue is coated by a thick, dry, 
yellow fur, with dull red fungiform papillae protruding at inter- 
vals; the mouth is parched, thirst is increased, and milk or water 



AFFECTIONS OF THE STOMACH AND INTESTINES. 205 

is taken greedily only to be quickly vomited again. The bowels 
are constipated, and when an evacuation does occur, it is attended 
by great straining, and the faeces appear in small, round, hard, 
light-colored lumps, often enveloped in mucus ; sometimes mode- 
rate diarrhoea alternates. The abdomen is distended and tym- 
panitic, and there is great tenderness over the epigastrium. Flesh 
is rapidly lost, the anterior fontanelle becomes sunken, the child 
is very fretful, has an aged and anxious expression of face, and a 
deep furrow may be noticed passing downward from the alae of 
the nose to encircle the mouth, giving to the lips the appearance 
of projecting. 

This condition continues, with occasional brief periods of im- 
provement, for several months. Then the vomiting becomes more 
constant, occurring both after food and in the intervals of feed- 
ing. It is excited by any disturbance, such a trifling act as wip- 
ing the mouth, for example, being sufficient, to bring on an at- 
tack. The stomach seems now to have lost its power to even 
begin the digestion of the blandest food, for if milk be given, it 
is vomited uncurdled and in the same state as when swallowed. 
Emaciation progresses very rapidly. The skin, dry and inelastic, 
hangs in loose folds from the limbs, and is apparently too large for 
the wasted body. It has a muddy color, and exhales an offensive, 
sour odor. The face is pinched, the eyes are sunken, though 
bright, with pearly sclerotics ; the nose is sharp, and the cheeks 
hollow. The infant lies with the knees drawn up against the ab- 
domen, and to this position they are at once returned when 
straightened out ; often the legs are moved about uneasily, in- 
dicating abdominal pain. There is little sleep either by day or 
night. Fretfulness is constant, with an occasional breaking out 
into loud, painful cries, or as weakness increases, into low wait- 
ings. The tongue is dry and heavily coated, the bowels continue 
constipated, and, toward the end, the abdomen becomes retrac- 
ted. The pulse grows weak and frequent in proportion to the 
failure in general strength, and the temperature falls below nor- 
mal ; the thermometer, placed in the rectum, often registering 
but 97 F. The breath is sour, and the scantily secreted saliva, 



206 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

perspiration and urine are all very acid. As death draws nearer, 
the surface is perceptibly cool to the touch, the hands and feet 
become blue, patches of thrush appear upon the inside of the lips 
and cheeks, the little patient lies utterly exhausted, dozing or 
half unconscious, and for several days before the fatal termination, 
the only evidences of life are the gentle rise and fall of the chest 
in breathing and the occasional expression of pain that flits across 
the face. 

Sometimes, in the last few weeks of the attack, certain of the 
symptoms become exaggerated, constituting what is termed 
"spurious hydrocephalus.' ' In this condition there is deep de- 
pression of the fontanelle, dilated pupils, transient flushing of 
the face, great languor, heaviness of the head, drowsines, semi- 
stupor, and even coma with stertorous breathing. Indications of 
pain and fever are, however, absent, The sunken fontanelle 
shows a deficiency in the amount of blood in the brain, but, as 
suggested by Parrot, there may be, in addition to this source of 
the symptoms, some toxic element analogous to that of uraemia. 
Thrombosis of the cerebral sinuses and intracranial hemorrhages 
are also occasionally found after death, but their connection with 
the ante-mortem phenomena is by no means uniform. 

When the disease terminates favorably the vomiting occurs at 
longer and longer intervals, and finally stops entirely, though 
there is great liability to a return on the slightest indiscretion. 
Afterward all the other symptoms disappear except the constipa- 
tion, which is apt to be obstinate. An excessive development of 
fat is a frequent sequel. 

Diagnosis. — The protracted course,-the frequent and obstinate 
vomiting of sour liquid, and the excessive emaciation, mark the 
disease with sufficient distinctness. The association of vomiting 
and constipation, and the development of the features of spurious 
hydrocephalus, are suggestive of tubercular meningitis. This 
disease is to be excluded by the depressed condition of the 
fontanelle, the regularity of the pulse, the tympanitic abdomen 
and the apyrexia. 

Prognosis. — Chronic vomiting is a dangerous affection, even 



AFFECTIONS OF THE STOMACH AND INTESTINES. 207 

under the best circumstances and an unfavorable result may be 
expected when the attack begins during the first three months, or 
occurs in a child who has been hand-fed from birth. The course 
is prolonged, extending from two to four or even six months. 

Treatment. — The first and most essential step in the successful 
management is a careful regulation of the diet. There are two 
ends to be attained; first, to give the stomach as much rest as pos- 
sible, and second, if a sour odor of the breath and body indicates 
that fermentation is going on in the viscus, to stop this process by 
withholding fermentable materials. 

In cases of moderate severity, where the vomiting has followed 
premature weaning, with a substitution of farinaceous food for 
the natural, a return to the breast is indicated. Or, if this be 
impracticable, the food must consist exclusively of sterilized milk 
guarded with lime water or diluted with barley water. For a 
child of three months a good proportion is two parts of milk to 
one of lime-water, or equal parts of milk and barley-water. Of 
either of these mixtures two fluidounces may be given every two 
hours, though the only guide to the proper quantity is the power 
of retention ; and if one measure be rejected, less must be given at 
the next feeding, until the proper amount is ascertained. Subse- 
quently, it may be increased as the stomach becomes retentive. 

In more severe and long-standing cases, attended by symptoms 
of acid fermentation, it is still advisable, with young infants, to 
try a return to the breast. In doing this, the fact that the mere 
act of sucking is sometimes sufficient to excite vomiting, must be 
remembered. So, before discarding the mother's milk as a food, 
an effort should be made to administer it with a spoon, after 
pumping it from the breast. It may then be retained and 
digested. However, the majority of patients in this stage of the 
disease can digest neither breast-milk nor any of the ordinary 
preparations of cows' milk, and time and even life may be saved 
by adopting at once an unfermentable diet, as a mixture of — 

Fresh Cream, f 3 ss. 

Whey, fgj. 

Barley-water, f^j. 



208 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Or— 

Weak veal broth (half a pound to the pint). 
Thin barley-water; in equal quantities. 

Either food is best given cold and in small quantities at short 
intervals. One teaspoonful at a time is enough in bad cases ; 
but when the amount is so small, the dose must be repeated every 
ten or fifteen minutes. As improvement occurs, the amount of 
food and the length of the intervals should both be increased. 
It is important always to forbid the use of a bottle and feed with 
a spoon. A careful observance of these details is frequently 
rewarded by a rapid cessation of the vomiting. After the 
stomach has been retentive for forty-eight hours an effort may be 
made to return to a milk diet and the bottle. The change may 
be begun with what is known among dairymen as " strip- 
pings/ ' This is the milk obtained by re-milking the cow 
after the udder has been once unloaded. It contains much 
cream and little casein. A combination of this sort : — 

Shippings, fgj. 

Water, f§ij-; 

administered every two hours agrees well. This mixture should 
be used for several days in gradually increasing quantities, until 
as much as six fluidounces every three hours can be borne with 
ease, then food of which sterilized milk is the basis may be 
safely resumed. For example : — 

Milk, fgiv. 

Cream, fgij. 

Milk sugar, gj. 

Water, fgij.; 

given from a perfectly clean bottle, every three hours. The 
substitution of lime-water or barley-water for water is advisable 
in case of slow digestion with colic ; so, too, is the addition of 
a teaspoonful of caraway-water if there be flatulence. Another 
good combination is — 



AFFECTIONS OF THE STOMACH AND INTESTINES. 209 

Milk, f3;iv. 

Cream, - . . f^ij. 

Mellin's food, 3J. 

Water, hot, to dissolve the Mellin's food, . f § ij. 

These foods are proportioned for infants of about three months. 
The importance of preparing each meal separately, and imme- 
diately before it is served, must not be overlooked. 

The second necessary step is to attend to the clothing and 
hygiene, A light, long-sleeved, woolen shirt, drawers of the 
same material, and thick worsted stockings, must be worn ; the 
latter especially should be insisted on, as it is essential to keep 
the feet warm. In addition, it is well to envelop the abdomen 
with a flannel binder. The clothing must be changed at reason- 
able intervals. Should it become soiled by vomit, it must be 
taken off at once and carried out of the room. The frequency 
of such accidents can be much lessened by placing a towel under 
the child's chin and over his chest, to receive the vomited 
matter. This, too, when soiled, is to be removed immediately 
and replaced by another, perfectly dry and fresh. The sick- 
room must be light and well ventilated, and no articles of body 
or bed clothing moistened with vomited matter should be allowed 
to remain in it a moment ; the proper temperature is 68° F. 

If the feet remain cold in spite of stockings, they should be 
rubbed from time to time with the dry hand, or with some stimu- 
lating liniment — oil of turpentine, fSij, and olive oil, fjij ; if 
this does not warm them, the legs, as far as the knees, may be 
put in a hot mustard foot-bath for five minutes. Hot flaxseed 
poultices, made light and dashed with mustard, will, when worn 
over the belly, relieve pain and fretfulness ; the same result 
follows repeated applications of the stimulating liniment. To 
promote free action of the skin, the whole body should be 
sponged with warm water twice a day, and afterward anointed 
with warm olive oil, which must be gently rubbed into the 
surface with the pulps of the fingers. If there be great prostra- 
tion, a full bath of ioo° F., with or without mustard, may be 
resorted to, the body being immersed from one to three minutes. 
18 



2IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Under such circumstances, it may also be necessary to envelop 
the legs in cloths wrung out of hot mustard water, and to keep 
bottles or rubber bags filled with hot water in close contact with 
the body in order to encourage reaction and maintain a normal 
temperature. 

Of medicines, wine of ipecacuanha, in a sufficient dose thor- 
oughly to rid the stomach of acid contents, prepares the way 
admirably for other measures, but should never be used when 
the strength is exhausted. Marked sinking of the fontanelle is 
always a contraindication. 

The ordinary means of relieving gastric irritability are of little 
avail in checking the vomiting in chronic catarrh of the stomach. 
The remedy that seems to possess most power to accomplish this 
is liquor potassii arsenitis. The proper dose for a child of three 
months is half a drop, three times daily, administered simply in 
a teaspoonful of water or combined with an alkali and aromatic, 
as: — 

R . Liquor. Potassii Arsenitis, TT\,xij. 

Sodii Bicarbonatis, gr.xxiv. 

Aquae Mentha^ Pip., q. s. ad fg iij. 

M. 

S. — One teaspoonful, in a little water, three times daily. 

When Fowler's solution fails there are several other drugs that 
may be tried. These are vinum ipecacuanhae, in drop doses 
every three hours ; calomel, one-sixth of a grain, every four 
hours ; salicylate of sodium, half a grain every two hours; and 
tinctura nucis vomicae, half a drop three times daily, combined 
with bicarbonate of sodium and an aromatic, as in the prescrip- 
tion just given. 

While these medicines are being administered, the bowels 
should be evacuated by laxative enemata. 

Prostration demands stimulants. The best is old whiskey, 
which may be given in ten-drop doses every two hours ; but the 
guide for the dose, as well as for the proper time to commence 
administration, is the condition of the fontanelle. 

When convalescence begins, half a drop of tincture of nux 



AFFECTIONS OF THE STOMACH AND INTESTINES. 211 

vomica, or fifteen drops of the ferrated elixir of cinchona, may 
be prescribed, and the tonic effects of fresh air and sun-light 
must be utilized by taking the child out of doors when the 
weather permits. 



3. ULCER OF THE STOMACH. 

This disease is not very uncommon in new-born infants, but is 
decidedly rare afterward. It may occur as a single, minute, round 
ulcer, with a perforating tendency as in adults, or as numerous 
small scattered erosions which stud the surface of the mucous 
membrane and assume the appearance of ulcerated follicles. 
The perforating ulcer has been ascribed to all the various causes 
which are held to be potent in producing the gastric ulcer of 
adult life, and it is probable that for children after they are 
weaned the pathology of the two may be the same \ but for new- 
born infants, circulatory disturbances which ensue somewhat 
suddenly at birth, the sudden arrest of the placental stream, the 
gradual development of the pulmonary circulation, associated as 
it often is with partial atelectasis, so potently predispose to 
venous stagnation in the abdominal viscera as to give much ground 
for the belief that congestion, and even ecchymosis, are at the 
root of the ulceration. 

The scattered ulceration has been found under such varied 
clinical conditions that it is impossible to attach any definite 
meaning to it, although one may suppose with reason that it is 
the result of some chronic catarrh. 

Symptoms. — Vomiting of blood and melsena are the only in- 
dications which point to the existence of an ulcer of the stomach 
in the infant. A healthy child within a few hours of its birth who 
begins to vomit blood and to pass pitchy matter per anum, may 
have a gastric ulcer. More than this we cannot say, for the same 
symptoms may certainly be present without any ulcer. In the 
few cases in which a gastric ulcer is present in older children, the 
symptoms, if definite, should be as in adults — epigastric pain and 



212 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

vomiting. The follicular ulcer cannot be diagnosed, and has 
always been found accidentally upon the post-mortem table. 

Treatment. — The bleeding in many cases is so quickly fatal 
that nothing is available ; cold alum whey may be given, and 
some castor oil, which, by acting upon the bowels, may do some- 
thing to relieve any local plethora which might exist. 

Tubercular ulceration of the stomach is occasionally met with, 
but it has no symptoms apart from those of tabes mesenterica. 



4. SOFTENING OF THE STOMACH (GASTRO- 

MALACIA). 

This condition has received a great deal of attention, and some 
of the most distinguished writers upon the diseases of children 
have credited it with being a distinct disease, but, to my mind, 
with insufficient reason. Of symptoms it has none which are in 
any way characteristic, and the appearances found after death 
are identical with those of post-mortem solution. Whether this, 
as well as other changes which are cadaveric in their nature, may 
not at times commence during the last hours of life may perhaps 
be an open question, but that the change is, in all cases, essen- 
tially what has been described as post-mortem solution there is 
no doubt. 

Goodhart has twice found evidence of a gastric solution of the 
lung, which had gone on during the life of the patient. Into the 
appearances of the parts it is needless to enter further than to 
say that they showed a distinctly peculiar broncho-pneumonia, 
and that in each case there had been a moribund condition 
associated with vomiting for some days before death. Now it is 
obvious that such a condition has no right to the position of a 
disease ; it would never have occurred had the circulation of the 
patient been at its proper tension. It was the result of an ebbing 
life, not a disease, which caused death. So it is with the gastro- 
malacia of children. It is the result of exhausting disease of any 
kind, and is virtually, if not literally, a post-mortem change. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 213 

5. CHRONIC GASTRO-INTESTINAL CATARRH. 

This disease is common in children who have passed the first 
dentition, and bears to them somewhat the same relation that 
chronic vomiting does to infants. Among the latter it is very 
uncommon, perhaps because the anatomical position and greater 
irritability of the stomach in the early months of life favor the 
rapid expulsion of improper or partially digested food, and the 
irritating products of gastric fermentation, which would other- 
wise, as in older children, pass through the pylorus and induce 
catarrh of the intestinal mucous membrane. The disease is met 
with in two forms, differing merely in the degree of catarrh. For 
convenience, they may be considered separately ; as, habitual 
indigestion, in which the catarrh is moderate in degree ; and 
mucous disease, in which it is intense. 

HABITUAL INDIGESTION. 

In the rare cases of this disease, where death has resulted from 
an intercurrent affection, post-mortem examination has revealed 
the gastro-intestinal mucous membrane, finely injected, reddened 
in patches, flabby, swollen and covered with a layer of tenacious 
mucus of variable thickness. In the majority of cases, though, 
it is probable that the catarrh does not extend beyond the grade 
that would leave no gross change after death. 

Etiology. — The predisposing agencies are deficient functional 
activity of the stomach, either existing simply as a factor of a 
weak constitution, or resulting from previous disease or ill-directed 
hand-feeding. Residence in large cities, and dark, close and 
damp houses ; too little out-door exercise, and too much con- 
finement and pushing at school; and finally, the eruption of per- 
manent teeth, belong to this class of causes. They all act by 
lowering the capacity to digest, and the best food imperfectly 
digested undergoes chemical changes rendering it irritant and 
capable of transforming the normal hyperemia of digestion into 
the congestion of catarrh. Fewer cases are met with in summer 



214 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

than in winter, because during the former season children live 
more out of doors, and the functions of the skin are more active, 
keeping a larger quantity of blood at the surface — a great safe- 
guard against catarrh. Season, then, may be added to the pre- 
disposing influences. 

The prime exciting cause is unsuitable food. As a rule, 
especially with children of the poorer classes, among whom the 
disease is very rife, the fault lies in the food being too strong. 
These children are allowed to sit at table and partake of what- 
ever the elders eat, such as meat two or three times a day, with 
potatoes, bread and butter and tea, none too well prepared or of 
too good quality. This coarse food, of itself irritating to the 
delicate lining of the stomach, is also very difficult to digest. 
The child may have force enough to maintain a fair degree of 
health against this odds for a while, and some even win in the 
race, but for most, the time of trouble surely and soon comes. 
Some portions of the food begin to escape, more or less com- 
pletely, the solvent action of the gastric juice. The starches and 
fats, influenced by the heat of the parts and the organic matter 
present, undergo fermentation, and are converted into acids with 
the liberation of carbonic acid gas ; the albuminoids become 
partially decomposed and acrid. These not only irritate the 
mucous lining of the stomach, but passing into the intestine, act 
upon its mucous membrane, and cause the same catarrhal lesions 
there. 

At first an attack of vomiting and purging, by cleaning out 
the alimentary canal, puts an end to the catarrh, and the patient 
is free from symptoms so long as the resulting anorexia restricts 
his appetite. But a return to the old diet is quickly followed by 
a relapse, culminating in another natural effort at relief; and so 
the attacks recur, growing more and more frequent and easily 
induced, until what was originally an acute and passing indiges- 
tion becomes chronic. 

As soon as the catarrh is established and the interior of the 
canal is covered with tenacious mucus, the disease begins to react 
upon and increase itself. For, whatever food is taken is soon 



AFFECTIONS OF THE STOMACH AND INTESTINES. 215 

enveloped by mucus, and this coating prevents the free access of 
the gastric and intestinal juices, which are solvents and antifer- 
ments. Mucus, too, is in itself a powerful ferment and increases 
the formation of irritating substances ; further, by covering the 
interior of the alimentary canal, it prevents the absorption of 
what little food is digested, leading to malnutrition, with a de- 
terioration in the quality of the gastric juice and succus entericus, 
and leaving more material for chemical change. Thus there is a 
direct and an indirect reaction. 

Well-to-do children are spared a coarse diet and, in conse- 
quence, do not suffer so severely. In them bad food takes the 
form of rich dishes, pastry, sweets and so forth. 

Exposure to wet and cold has some excitant influence, though, 
without the aid of bad diet, it is scarcely sufficient to induce an 
attack. 

Symptoms. — When the disease is fully developed, the patient 
has a spare, delicate appearance, the face wears a languid expres- 
pion and is pale ; the pallor at intervals increasing very much, or 
again giving place to flushing of one or both cheeks. The hair 
is crisp and lustreless. The conjunctivae are sometimes natural, 
but more often slightly yellow. The skin is cool, dry and rough 
to the touch, and somewhat sallow in hue. The pulse is weak, 
but otherwise unaltered. The mucous membrane of the mouth 
is less pink than normal ; the breath has a heavy, disagreeable 
odor; the tongue is pale, broad and flabby, frequently indented 
by the teeth, and covered with a thin, white frosting, which 
grows thicker, and more yellowish toward the posterior part of 
the dorsum. Through this coating the enlarged fungiform papillae 
project, and are redder than the rest of the mucous membrane, 
but not so highly colored as in acute gastric catarrh. Moderate 
hypertrophy of the tonsils can frequently be observed, and, as a 
rule, the cervical lymphatic glands are slightly enlarged. 

The appetite is variable and perverted, the desire being for 
highly- seasoned food. After eating, eructations of flatus occur, 
and small quantities of partially digested food, mixed with thin 
mucus and intensely sour, are from time to time regurgitated 



21 6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

from the stomach. Tympanites is a constant symptom, and when 
the child is stripped the distended abdomen contrasts markedly 
with the spare trunk and limbs. Pain is uniformly present. It 
may be constant or paroxysmal, severe and colicky, or only 
amounting to discomfort, and either general or confined to cer- 
tain parts of the abdomen. Usually it is paroxysmal, beginning 
from two to three hours after meals ; if constant, it is subject to 
exacerbations at these periods. Generally, too, it is only mod- 
erately severe, and is confined to the left or right hypochon- 
driac region. The reason for this limitation being, that in both 
positions, but especially in the first, the colon makes a sharp turn 
where the gases, liberated by fermentation, become lodged. On 
account of the mucus covering the faecal masses as well as the in- 
terior of the bowel, bringing two slippery surfaces together, the 
peristaltic contractions are less efficacious, and constipation re- 
sults. Intervals of two, three, or even nine days elapse between 
the movements, which are attended by considerable straining, 
and result in the expulsion of a small number of dark, hard lumps 
enveloped in mucus. 

The urine, at times, is scanty and high colored, at others, over 
abundant and light colored. The diminution is apt to attend 
exacerbations of abdominal pain. 

During the day the child is listless, disinclined to play and 
easily tired, while at night he tosses about the bed in a dreamy 
sleep. 

To the above symptoms catarrh of the nasal and bronchial 
mucous membranes is often added. 

It is usual for the even course of the disease to be broken by 
vomiting and diarrhoea. In such attacks there may be slight 
fever, the tongue becomes more heavily coated, the appetite fails 
and thirst is increased. The vomited matter at first is composed 
of acid, partially digested food, mixed with stringy mucus; after- 
ward, if there be much retching, of more or less bile-stained mu- 
cus alone. The purging, primarily, unloads the bowel of a large 
quantity of lumpy faeces, apparently the collection of several 
days; afterward, the stools are made up of mucus and liquid 



AFFECTIONS OF THE STOMACH AND INTESTINES. 21 fj 

faeces. Such attacks last one or two days, and are followed by a 
brief period of improvement. 

The Diagnosis is easy. 

The Prognosis is favorable, though, when left to itself, the 
disease runs a protracted course, improving in summer to return 
in winter. By the general debility that it produces, it opens the 
way to intercurrent affections, or the development of hereditary 
tendencies, and renders both more fatal. 



MUCOUS DISEASE. 

This form of chronic gastro-intestinal catarrh occurs much less 
frequently than the other. It consists of a mucous flux from the 
whole internal surface of the alimentary canal, which interferes 
mechanically with the digestion and absorption of food, and so 
impedes nutrition as to suggest the presence of tubercles. The 
lesions are identical in kind with those of habitual indigestion, 
but are much greater in degree. 

Etiology. — The affection usually arises between the fourth and 
twelfth years, and has the same predisposing and exciting causes 
as the milder form. There are two conditions, however, under 
which the disease is especially apt to arise, namely : the eruption 
of the permanent teeth, and attacks of whooping cough. 

The influence of the former is explained by the intimate sym- 
pathy existing between the different portions of the digestive 
tract, on account of which the irritation of the mouth during 
dentition is reflected throughout the intestinal tract, producing 
increased secretory activity and greater susceptibility to irritants. 

During the course of whooping cough, the gastro-intestinal 
mucous membrane is always in a catarrhal state. Much of the 
tenacious mucus expelled at the end of each paroxysm comes 
from the stomach. When vomiting occurs, most of the matter 
ejected is mucus, and the stools contain a quantity of the same 
substance. As the cough subsides, the secondary catarrh usually 
disappears, but after severe attacks, and in feeble children, it 
may continue, and pass into mucous disease. 



2l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Symptoms. — As might be expected from what has already been 
said in regard to lesions and causation, the symptoms, in the 
main, are those of habitual indigestion greatly magnified. 

The child is emaciated and muscularly weak. His face is 
uniformly pale, though subject to great changes in color, and at 
times a circumscribed crimson flush appears on one or both 
cheeks ; at others, there is so much pallor, especially about the 
lips, that fainting seems imminent, and, indeed, it does some- 
times occur. The eyes are surrounded by bluish circles, which 
deepen when the face pales. The conjunctivae are muddy, and 
there is occasional squinting. The skin is markedly sallow, dry 
and rough to the touch and, by light friction, numerous fine 
scales of dead epidermis can be removed, and the hair has a 
lustreless, faded appearance. The cervical lymphatics are notice- 
ably swollen, though painless. 

The oral mucous membrane is pale. The tongue, besides 
being flabby and indented by the teeth, presents an appearance 
characteristic of the disease. The dorsum, with the exception 
of an oval space in the centre, is covered with a light gray coat- 
ing, scarcely thick enough to obscure the natural pale-pink color, 
and shows clearly the slightly redder fungiform papillae. The 
oval bare spot, about as large as a cent, is still deeper red, and 
shines as though varnished. This glossy look, in very severe 
cases, extends over the whole dorsum, and is due to an excessive 
secretion from the mucous glands of the mouth. Such a tongue 
does not lose the natural velvety appearance arising from the 
fungiform papillae. (See a, Plate 2.) 

Chronic hypertrophy of the tonsils, with plugging of the folli- 
cles by retained secretion, is common, and, in part, accounts for 
the disagreeable odor of the breath. 

The appetite in the beginning fails, then becomes capricious, 
and, finally, almost insatiable. The increased desire for food is 
due partly to a morbid craving, excited by the irritation of the 
fermenting contents of the stomach and intestines, and partly to 
the demand of the tissues generally for more nutriment than is 
supplied by the imperfect digestion and impeded absorption. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 219 

Eating is followed by a sensation of drowsiness, and by eructa- 
tions of flatus and acid liquid. 

Tympanitic disteution of the belly is always marked, and the 
child complains of pain in this portion of the body. The pain 
may be general, when it amounts to little more than a sensation 
of soreness, but more frequently it is limited to the left hypo- 
chondrium, and is stitch-like in character. Either variety may 
be constant, or present only after meals ; in the former case there 
is a temporary increase of discomfort after eating. In some 
instances, paroxysms of severe pain in the neighborhood of the 
umbilicus occur early in the morning, and occasionally after 
meals. These are unattended by nausea, purging, or doubling 
of the body to secure relief, as in colic, but while they last, the 
pallor of the face is extreme. 

Constipation is the usual condition of the bowels. Evacu- 
ations take place at intervals of several days, with much straining, 
and at times rectal prolapse ; they are scanty, and composed of 
small, hard, dark-colored lumps, with a large proportion of mucus, 
and often contain intestinal parasites or their ova. Sometimes 
the constipation lasts for a week or more at a time, to be followed 
by a number of free evacuations in quick succession, relieving 
the bowel of the accumulated faeces ; then comes another period 
of confinement, another relief, and so on. 

By day, the patient suffers from headache ; is languid, ill- 
tempered, and disinclined for study or play. At night, he is 
restless ; grinds his teeth ; starts from sleep in terror caused by 
frightful dreams, and often screams or talks incoherently, and 
for a time is seemingly unconscious of his surroundings. Som- 
nambulism and nocturnal incontinence of urine are quite common. 
Stammering is another nervous symptom occasionally encoun- 
tered. 

There is no alteration in the temperature ; the pulse is feeble, 
and there is frequently a slight, dry, hacking cough, entirely in- 
dependent of pulmonary disease. The urine is diminished during 
the continuance of severe pain, but is voided in excessive quanti- 
ties at the termination of the paroxysms. 



2 20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

At intervals of two or three weeks violent vomiting and purg- 
ing occur. During these attacks, which last from one to three 
days, a large quantity of mucus is rejected ; there is slight fever, 
and the tongue is changed in appearance, and for the second 
time assumes a characteristic aspect. It becomes less flabby, 
more pointed, and covered with a thick, white, feathery fur, 
except along the sides, where there are several smooth, bright-red, 
glazed patches of variable size and shape, with irregular, indented 
edges. A few red fungiform papillae show through the coating. 
Sometimes the whole dorsum is clean, red, and glazed, as if de- 
nuded of epithelium. (See b> Plate 2.) Temporary improve- 
ment follows the clearing-out process, but soon the symptoms 
return, and slowly grow worse to culminate in another attack. 

The course of the disease is very chronic, extending over 
months. There is no regular progression, though the tendency is 
for the symptoms to grow more and more severe as time elapses. 

Diagnosis. — Tuberculosis is the condition most likely to be 
confounded with the disease in question, and the mistake is 
especially apt to be made when a dry, hacking cough is present. 
The appearance of the symptoms after whooping cough or dur- 
ing second dentition; the state of the tongue; the mucous stools; 
the condition and color of the skin ; the absence of pyrexia 
except during the attacks of vomiting and purging ; the perio- 
dicity of these attacks; the diurnal drowsiness and nocturnal 
terrors, and the irregularity in the course are the distinguishing 
features. 

Prognosis. — Mucous disease is not in itself mortal, and is per- 
fectly amenable to treatment. It is, nevertheles, dangerous from 
its power to reduce the general nutrition, thus opening the way 
for more serious intercurrent affections. 

As the plan of managing both forms of chronic gastrointes- 
tinal catarrh is the same, it is unnecessary to divide the 
subject of — 

Treatment. — Since the exciting cause is perfectly well known 
and removable, relief may be confidently promised, provided it 



AFFECTIONS OF THE STOMACH AND INTESTINES. 221 

be possible to regulate the diet. There are two rules to be in- 
sisted upon : first, to stop the supply of all those articles of food 
that readily undergo fermentation ; and, second, to allow only a 
moderate quantity of food at a time, so as not to overdistend 
the stomach, while the meals are increased to four a day, to 
insure the ingestion of a proper amount of nourishment. 

All farinaceous substances must be excluded from the dietary 
save stale or toasted bread, and this, even, must be restricted 
in amount. Potatoes, peas, beans, turnips, carrots, parsnips, fruit, 
cakes, pastry, sweetmeats and butter are all in the proscribed 
list. 

Of permissible articles, milk, eggs, and lean meat are the chief, 
though fresh fish, raw oysters, cauliflower tops, spinach, aspara- 
gus, lettuce and celery can be used without ill effect. With such 
food to select from, it is easy to write out a suitable diet list and 
make changes sufficiently often to avoid cloying the appetite by 
monotony. In writing such lists, it is best to fix the hour, as 
well as the ingredients, of each meal. For example : — 

Breakfast, at 7 a m. — One or two tumblerfuls of milk guarded 
by lime-water* (fgij to fgvj), the yolk of a soft-boiled egg 9 and 
a single thin slice of stale, unbuttered bread. 

Luncheon, at 11 a.m. — A cup (fj iv) of beef-tea, or mutton 
broth, entirely free from fat,f and a thin slice of dry toast. 

Dinner, at 2.30 p.m. — Broiled mutton chop, entirely free from 
fat, one or two, according to the size ; a large spoonful of well- 
boiled spinach, and a slice of stale, dry bread. 

Supper, at 7 p.m. — One or two tumblerfuls of milk guarded by 
lime-water, and a slice of dry toast. 

Filtered water must constitute the drink, though, if the child 
will take it, half a tumblerful of Vichy at luncheon and dinner 
can be recommended. 

* The lime-water is added both for the purpose of retarding coagulation 
and for its effect upon the mucus in the alimentary canal. 

f The fat can be completely removed by allowing the broth to stand for a 
few minutes after it is made, and picking oif the globules of oil as they rise to 
the surface with a fragment of blotting-paper. 



2 22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Should failing appetite demand a change, another menu must 
be made, as : — 

Breakfast. — Milk, a bit of boiled fresh fish, and a thin slice of 
unbuttered toast. 

Luncheon. — The soft parts of six or eight small oysters, sea- 
soned with salt alone, and a Boston cracker. 

Dinner. — A bit of the breast of a roasted or boiled fowl, a 
moderate portion of well-boiled cauliflower tops, and a slice of 
stale, dry bread. 

Supper. — Milk and dry bread. 

Further variety can be had by substituting a thin slice of cold 
roast mutton or beef for the egg or fish at breakfast; at dinner, 
by running the changes on roast mutton, broiled beef-steak, roast 
beef, plainly cooked game, and such vegetables as stewed celery, 
boiled asparagus tops, spinach and cauliflower; by using different 
sorts of meat broths, and by changing the manner of cooking 
the eggs. 

When, in mucous disease, there is great debility, stimulants 
are indicated. They should be given well diluted and with the 
meals. Whiskey and old dry sherry are the best. Of the first, 
one or two teaspoonfuls in a fourth of a tumbler of ice-water 
may be given with lunch and dinner; of the second, one or two 
tablespoonfuls with twice as much water at the same meals. 

Next to regulating the diet it is important to maintain the 
activity of the skin. This is to be accomplished by baths, in- 
unctions and proper clothing. Each morning the patient, being 
in a warm room, should be sponged with water at a temperature 
of 6o° F., then thoroughly rubbed down with a coarse towel, and 
the whole body anointed with warm olive oil, which ought to be 
gently rubbed into the skin with the finger pulps. At bedtime a 
full bath of ioo°, of five minutes' duration, must be given, and 
the inunction repeated, after careful drying with friction. In 
severe cases, where the skin is very dry and rough, the first warm 
bath should contain a heaped tablespoonful of soda, and with 
this and soap the whole surface must be thoroughly scrubbed. 

Woolen underclothing, to cover completely the trunk and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 223 

limbs, and woolen stockings are to be insisted upon. The weight 
may be changed with the weather, but not the material. This 
not only keeps the skin warm, full of blood and functionally 
active, but it also maintains the heat of the whole body and 
saves force. Children dressed for beauty with four or five inches 
of bare leg, nine times out of ten suffer from chronic indigestion 
or bronchitis. First, because chilling of the surface drives the 
blood toward the interior and puts the mucous membranes in the 
most favorable conditions for catarrh ; secondly, because so 
much force is consumed in maintaining the normal temperature 
in the face of constant chilling that other functions, notably the 
digestive, must suffer. Parents would appreciate this better if 
they could be persuaded to try the experiment of sitting, for an 
hour or so, even in a warm room, in the same degree of naked- 
ness that they inflict on their children, who are less robust and 
less able to resist cold. 

Exercise in the open air on suitable days in winter, and an 
almost complete out-door life in summer, hastens recovery. 
The sleeping and living rooms should be large, light, dry, well 
ventilated and properly warmed. 

Medicinal treatment is of minor importance, but by no means 
to be neglected. The indications to be fulfilled are to check the 
secretion of mucus ; to neutralize the acids formed by fermenta- 
tion of the food ; to restore the mucous membrane to a normal 
condition, thereby improving secretion, digestion and appetite, 
and to secure regular action of the bowels and the expulsion of 
collected mucus and faeces. These accomplished, strength and 
health return, though it may be necessary to call in the aid of 
tonics. 

Alkalies are the best remedies to check the secretion of mucus, 
and to liquefy it so that it may more readily be removed. They 
are also most efficient in neutralizing the acid products of fer- 
mentation. Simple bitters, too, have some power in lessening 
the formation of mucus, and considerable influence in arresting 
fermentation ; at the same time they give tone to the mucous 



2 24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

membrane and stimulate digestion. Laxatives keep the bowels 
clear. Of the first class, bicarbonate of sodium ; of the second, 
gentian or calumba ; and of the third, senna or aloes, are to be 
preferred in treating this disease. 

In habitual indigestion, a combination like the following will 
be all that is required : — 

R. Sodii Bicarbonatis, gj. 

Ext. Senn?e Fluid., f.^iij* 

Inf. Gentianae Comp., q. s. ad f^iij. 

M. 

S. — Two teaspoonfuls three times daily before eating, at 
the age of seven years.* 

Should there be yellowness of the conjunctivae and marked 
sallowness of the skin, indicating a slight degree of catarrhal 
jaundice, it is well, at first, to substitute equal doses of chloride 
of ammonium for the bicarbonate of sodium in this prescription. 

In mucous disease a similar prescription, with minute doses of 
iodide of potassium to increase the salivary secretion, may be 
ordered before meals, as: — 

R . Potassii Iodidi, gr. vj. 

Sodii Bicarbonatis, £j. 

Ext. Sennse Fid., f.^'ij- 

Inf. Calumbae, q. s. ad f § iij. 

M. 

S. — Two teaspoonfuls three times daily before eating. 

After food, it is well to order from ten to twenty drops of tinc- 
ture of myrrh in a little water, for its powerful tonic action on 
the intestinal mucous membrane. 

Aloes is valuable not alone as a laxative, but in arresting the 
mucous flux and bracing the mucous membrane. It can be 
administered in the form of tincture of aloes and myrrh, in doses 

*A11 of the subjoined prescriptions are proportioned for children of this age. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 225 

of twenty drops, three times daily after eating. Or, if the child 
be able to swallow a pill, it may be combined thus: — 

U . Pulv. Ipecacuanha, gr. iv. 

Pil. Aloes et Myrrhae, gr. xij. 

Ext. Gentianae, gr. vj. 

Ext. Taraxaci, gr. xij. 

M. et ft. pil. No. xij. 
S. — One pill three times daily an hour after eating. 

When there is much debility iron is demanded, and if the pro- 
per form be selected, it may be given in spite of a coated tongue, 
the usual contraindication. A good formula is: — 

R. Ferri Sulphatis Exsiccati, gr. xij. 

Tr. Aloes et Myrrhse, ^E 1V - 

Syr. Rhei Aromat., q. s. ad f^iij. 

M. 

S. — One teaspoonful three times daily after meals. 

From this prescription there is an astringent action, by the iron 
and rhubarb, which tends to check the formation of mucus ; a 
laxative action, by the aloes and rhubarb, keeping the bowels 
clear of mucus and faeces ; while the myrrh is a direct tonic to 
the relaxed mucous membrane. 

If, as the tongue cleans, the improvement under this plan comes 
to a stand, it is advisable to change to an acid treatment. There 
are several useful prescriptions, for instance : — 

R. Pepsin. Saccharat., ^ij. 

Acidi Muriatici dil., f 3 ij. 

Aquae Cinnamomi, q. s. ad f^iij. 

M. 

S. — One teaspconful three times daily after eating. 

Or the acid may be combined with a bitter : — 

R. Acidi Muriatici dil., f^ij. 

Inf. Gentianae Comp., q. s. ad f^iij. 

M. 
S. — One teaspoonful three times daily after meals. 

*9 



2 26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

R . Quinise Sulphatis, gr. xij. 

Acidi Muriatici dil., fgij. 

Aquae Cinnamomi, . . . . q. s. ad f^iij. 

M. 

S. — One teaspoonful three times daily after meals. 

All of these prescriptions must"" be well diluted and taken 
through a glass tube. 

During the periodical attacks of vomiting and diarrhoea, so apt 
to occur in both forms of the disease, the child must be put to 
bed, restricted to a diet of milk and meat broths, and ordered 
the following prescription : — 

R . Pepsinae Saccharat., 

Sodii Bicarbonatis, aa ^j. 

Pulv. Aromatici, gr. xij. 

M. et ft. chart. No. xij. 
S. — One powder four times daily. 

The diarrhoea must not be interfered with unless it become 
excessive, when it may be held under control by adding five 
grains of subcarbonate of bismuth to each of the alkaline powders. 

After the tongue becomes normal and the active symptoms 
have disappeared, the general strength must be built up by a 
course of tonics. The best, are tincture of nux vomica, ferrated 
elixir of cinchona, and bitter wine of iron. In order to prevent 
a relapse, mixed diet must be avoided for at least two months 
after convalescence is fully established, and to confirm the cure, 
change of air, by a trip to the sea-shore or mountains, is ad- 
visable. 

Both habitual indigestion and mucous disease are occasionally 
attended by a troublesome symptom that demands brief con- 
sideration. This is a peculiar cough, which is dry, paroxysmal, 
and unattended by lesions of the throat or lungs. The par- 
oxysms are due to reflex causes ; they commence in the early 
evening, and may, by their repetition, prevent sleep for half the 
night. On the following day the patient is as well as usual, or 
coughs only at long intervals, but about bedtime the trouble 
begins again. So the symptom continues for weeks at a time, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 227 

unless its true nature as a " stomach cough " be recognized and 
it is properly treated. The paroxysms suggest those of pertussis, 
though they may be distinguished by the absence of whooping, 
and of the characteristic expulsion of tenacious mucus at the end 
of the kinks. Questioning often reveals the fact that the cough 
is worse after a rich and heavy supper: 

If proper clothing be worn, the diet carefully regulated, and 
alkalies prescribed, as for an ordinary case of chronic gastro- 
intestinal catarrh, improvement is rapid, for in this way the 
cause is removed. Ordinary cough mixtures do more harm 
than good, from their tendency to derange digestion ; still, the 
fatiguing cough must be relieved. This can be done by letting 
the child wear a small bean-shaped belladonna plaster over the 
larynx, and administering a dose of one of the following mix- 
tures every two hours, beginning at four o'clock in the after- 
noon : — 

R. Pulv. Aluminis, gr. xlviij. 

Potassii Bromidi, £ij. 

Syrupi Zingiberis, 

Aquae, aa f g iss. 

M. 
S. — Dose, one teaspoonful. 
Or— 

R . Ext. Belladonnae, gr. ss-j. 

Pulv. Aluminis, gr. xlviij. 

Syrupi Zingiberis, 

Aquae, aa f g iss. 

M. 
S. — Dose, one teaspoonful. 



6. ACUTE INTESTINAL CATARRH. 

The condition intended to be indicated by this title is usually 
called simple or non-inflammatory diarrhoea, and classed as a 
functional disease. But from its etiology, and from the fact that 
in certain patients and under certain circumstances it so readily 
lapses into entero-colitis, it is more than probable that it depends 



2 28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

upon a distinct, though passing lesion — a hyperemia or catanh 
of the intestinal mucous membrane. This is difficult to demon- 
strate, partly because the opportunity for post-mortem inspection 
is rare in simple diarrhoea, and also on account of the well- 
recognized rapidity with which the appreciable manifestations of 
mild .forms of catarrh disappear after death. Nevertheless, even 
those authors who advocate the functional character of the affec- 
tion, state that in some instances of death, in feeble children or 
from intercurrent disease, autopsy shows injection, swelling, and 
relaxation of the mucous membrane, and tumefaction of the 
intestinal glands. 

Etiology. — Constitutional feebleness and unfavorable hygienic 
surroundings, especially residence in crowded, damp, and filthy 
houses and quarters of cities, increase the liability to attacks of 
diarrhoea. Many more cases occur in summer than at other 
seasons of the year. Children of either sex, or of any age, may 
be affected, though the younger the patient the more serious the 
disease. 

In infancy there are numerous exciting causes. Over-feeding, 
even with healthy breast-milk or well- prepared cows' milk, is 
one. Ordinarily, in such cases vomiting is so easy that the child 
gets rid of the surplus and no harm is done ; but if this does not 
happen, the excess remains undigested ; undergoes change ; acts 
as an irritant to the intestinal mucous membrane, and causes 
diarrhoea. Another cause is food of bad quality ; either poor 
and cholesterin-laden breast-milk, or unsound cows' milk and 
farinaceous preparations. Here the action is the same as in over- 
feeding, though more rapid and violent ; this is especially true 
of the farinacea, on account of their readiness to undergo acid 
fermentation. Again, exposure to cold and wet, by chilling the 
surface and determining the blood to the interior of the body 
and mucous membranes, may lead to an intestinal catarrh in the 
same way that it does, more frequently, to a bronchial catarrh. 
Hyperaemia, too, of the mucous membrane of the alimentary tract 
is attended by a diminution in the secretion of digestive solvents 
and an increased production of mucus; two conditions most 



AFFECTIONS OF THE STOMACH AND INTESTINES. 229 

favorable to incomplete digestion and fermentation of the food 
with the formation of irritant products. These, as already seen, 
are quite capable, in themselves, to cause looseness of the bowels, 
and must greatly add to the ill effects of exposure. High atmos- 
pheric temperature is much more influential than low, particu- 
larly when associated with excessive moisture. Such conditions 
are powerful depressants to the vital forces; the digestion shares 
in the general weakness, and much of the food is left to ferment 
and become irritant. Finally, dentition is a frequent cause. 
During this process, the whole digestive tract sympathizes with 
the condition of the mouth, and becomes less able to perform its 
functions and more susceptible to irritants. 

After the eruption of the milk teeth the use of unsuitable food 
and the disturbing influences of second dentition are the chief 
causes. 

It is almost unnecessary to call attention to the lesson taught 
by this study of the etiology. There is, on the one hand, the 
presence of an irritant as a constant factor ; on the other, a 
mucous membrane naturally delicate and functionally very active. 
The conclusion is inevitable, that the ordinary effect must follow, 
and hyperaemia or catarrh be produced. 

Symptoms. — In infants, the attack may begin suddenly, or be 
preceded for twenty-four hours or more by peevishness, languor, 
faded cheeks, slight abdominal pain, indicated by moaning or 
fits of crying, and restless, disturbed sleep. 

Next, the bowels become disturbed. The movements number 
from four to eight in the twenty-four hours, and usually occur 
only while food is being taken — from six in the morning to ten 
o'clock at night. At first they differ from the normal, merely in 
being more liquid and copious, and having a more offensive odor. 
As the disease progresses they undergo various changes. Some- 
times they are composed of a yellowish liquid containing white 
or yellowish flakes resembling curdled milk. At others, distinct 
white lumps of undigested curd are mixed with the liquid. Still 
again, green flakes may appear in a stool having the characters 
of the first ; and finally, the whole may be of a deep green color, 



230 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and contain small masses of mucus. In exceptional cases a small 
amount of bright- colored blood may be seen in the evacuations. 
Often the movements are preceded, for a short time, by pain, but 
this disappears as soon as the act is accomplished. Occasionally, 
if the stools be acid, considerable tenesmus attends their expul- 
sion, and it is under such circumstances that blood is most likely 
to be voided. 

The tongue is lightly coated ; there is anorexia ; increased 
thirst, and occasionally nausea and vomiting. The abdomen is 
natural in shape, and is soft and painless on palpation. The 
urine is somewhat lessened in quantity, and high colored. There 
is no pyrexia, and the pulse is but slightly increased in frequency. 

The evil effect of several days' continuance of diarrhoea upon 
the general condition of the child is shown by the pallor of the 
face, the sunken eyes, the loss of weight and the flabbiness of 
the muscles. Under proper management the attack terminates 
in from four to seven days, and strength is soon restored. 

Simple diarrhoea is more uncommon in older children and 
much milder in its manifestation. There is slight furring of the 
tongue, loss of appetite, and abdominal pain of a colicky nature, 
with more or less frequent evacuations of light yellow, offensive, 
semi-solid or liquid faecal matter, at times containing masses of 
partially digested food. The patient is weak and disinclined to 
exert himself. These attacks last for three or four days, and are 
followed by little constitutional depression. 

Diagnosis. — There is no difficulty in distinguishing the disease. 
The only conditions for which it could possibly be mistaken are 
tubercular diarrhoea and entero-colitis. The former is excluded 
by the history and course of the case and by lack of evidence of 
tuberculosis of other portions of the body ; the latter, by the 
apyrexia and the non-existence of symptoms indicating intestinal 
inflammation. 

Prognosis. — The result of even the more serious attacks in 
infants is, in the great majority of cases, favorable ; nevertheless, 
it must not be forgotten that an acute catarrhal diarrhoea, when 
it occurs in a weak, ill-fed and badly cared-for child during hot 



AFFECTIONS OF THE STOMACH AND INTESTINES. 23 1 

weather, has a tendency to run into entero-colitis, and thus prove 
fatal. An infant, too, may be so debilitated by previous illness 
as to be carried off by an attack of ordinary severity. 

Treatment. — Before entering into the details of the manage- 
ment of this disease, it is necessary to draw attention to the con- 
servative nature of the diarrhoea. The frequent, loose and copious 
stools clear the intestines of irritant matter, and remove the 
cause of further trouble. Consequently, it is never advisable, 
early in the course, to completely arrest the evacuations, 
although at the same time they must be kept well in hand, lest 
the attack pass into entero-colitis. During dentition, particu- 
larly, this caution must be observed, for when there are three or 
four loose passages daily, cerebral symptoms are much less apt to 
arise. 

As in other digestive disorders, the most essential step is to 
attend to the feeding. With infants nursed at a healthy breast it 
is enough to see that they are not fed too frequently, and to 
lessen the quantity taken by shortening each act of sucking. If, 
from any cause, the breast-milk be unsuitable, the babe must be 
weaned and carefully fed by bottle. In hand-fed babies it is 
necessary, first, to insist upon the use of the old-fashioned bottle 
and tip, and to see that they are kept absolutely clean. Next, to 
banish all farinaceous preparations, used purely as foods, from the 
diet. This does not preclude the employment of small quantities 
of arrow-root or barley-water for the purpose of breaking up 
the milk curd. Thirdly, to direct that the daily supply of milk 
— the only food to be allowed — must come from one dairy ; be 
received fresh in the morning, and kept in a separate, perfectly 
clean vessel, and, if possible, in an especial refrigerator. And 
finally, to give careful, written orders as to the manner of pre- 
paring the milk food, and to make a rule that each bottle shall be 
mixed separately and only immediately before it is required. In 
hot weather it is advisable to sterilize the whole supply of milk, 
but this does not affect the principle of the separate preparation 
of each portion. 

As guides to the manner of preparing the food, two formulae 



232 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

may be given ; they are proportioned for children of four to six 
months. 

Unskimmed milk, fg iijss. 

Cream, fgss. 

Lime-water, f ^ Ij. 

Mix these in a clean bottle, and warm by standing in hot water. 
Five to six bottles to be taken during the day. 

Or— 

Unskimmed milk, f ^ iijss. 

Cream, f^ss. 

Arrowroot water,* f^ij. 

Sugar of milk, gj. 

Mix and treat as before. 

The quantity is to be reduced and the dilution increased in pro- 
portion to the youth of the infant, and the reverse as age increases. 
Sometimes in children of one or two months a cream and whey 
mixture suits better, as : — 

Fresh cream, fgj. 

Whey, fgij. 

Hot water, f^ij- 

When there is thirst, cool water and bits of ice ought to be 
given with moderate freedom. 

The sleeping room should be airy, well ventilated, and, in hot 
weather, the coolest the house affords. Soiled diapers, or the 
vessel containing a stool, must not be left about. In summer the 
patient should pass the mornings and evenings in the open air, 
and the hot mid-day in a cool room. A day's excursion on a 
steamboat, or to the country, if the journey be short, is very 
beneficial, while a trip to the sea-shore works wonders ; a single 
day passed in salt air often removing every trace of the disease. 
Even in winter, if an attack occurs, the child, well wrapped up, 

* Take one and a half teaspoonfuls of arrowroot, rub it down with a table- 
spoonful of cold water until smooth, and add, with stirring, a pint Of boiling 
water. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 233 

should be taken out for an hour at noon on warm, sunny, still 
days. 

The daily bath must be continued, and in hot weather a bath 
morning and evening is none too much. Woolen drawers and 
shirts of the lightest texture must be worn in summer, and if the 
diarrhoea prove at all obstinate, the abdomen must be enveloped 
in a light flannel bandage. 

The condition of the mouth must always be investigated, and 
if the gums be hot and swollen, from approaching teeth, lancing 
is indicated. If there be much pain, with hardness of the gums, 
relief can be obtained by rubbing them gently at intervals with 
paregoric and water, ten drops to the teaspoonful, or with a solu- 
tion of chloride of zinc, one grain to the fluidounce. 

When these measures are carefully carried out in mild cases, 
medicines are often unnecessary. In those more severe, it is well 
to assist nature and begin the treatment with a laxative. Pain, 
green stools and the presence of blood always indicate this course. 
The best laxative is castor oil. This not only efficiently clears 
away the irritating contents of the intestines, but has a second- 
ary, soothing action upon the mucous membrane. For a child 
of six months, the dose is a teaspoonful, with five drops of cam- 
phorated tincture of opium to prevent griping. 

After this has operated, a teaspoonful of chalk mixture every 
two hours will complete the cure in some instances. A more effi- 
cient prescription, however, is : — 

R . Sodii Bicarbonatis, 3 ss. 

Syrupi Rhei Aromat., f.l ss « 

Aquae Menthae Pip., q. s. ad f§iij. 

M. 

S. — Teaspoonful every two hours. 

The great value of rhubarb depends upon its combined laxa- 
tive and astringent action, precisely what is required in simple 
diarrhoea. 

Should the stools still fail to become less frequent and more 
20 



234 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

natural in color and consistence, resort must be made to opium 
and astringents. A very good formula is: — 

R . Tr. Opii Deod., TT\,vj. 

Bismuth. Sub-nitrat. (Squibb) , £j. 

Syrupi, fgss. 

Misturse Cretse, q. s. ad f^ iij. 

M. 
S. — Teaspoonful every two hours. 

The value of calomel in certain cases where the evacuations 
obstinately remain green and acrid must not be overlooked, 
though the necessity for its use is rare. It must be employed 
cautiously and in small doses, and combined with an alkali, 
thus : — 

R • Hydrargyri Chloridi Mit., gr. j. 

Cretae Praeparatae, gj. 

M. et ft. chart. No. xij. 
S. — One powder every two hours. 

Its good effect should be noted in twenty-four hours, then it 
must be discontinued, and one of the other prescriptions given. 

When the stools become normal, wine of pepsin must be 
ordered for a week or more until the digestion is put upon a 
sound footing. 

In older children the treatment is very simple. All that is 
required is a bland diet, perhaps a dose of castor oil, and some 
mild astringent mixture. For example, let the patient take for 
breakfast— a soft-boiled egg ; milk guarded with lime-water, and 
stale, dry bread ; for dinner — some meat broth, free from fat ; 
stale, dry bread, and rice and milk pudding ; and for supper — 
milk, and stale, dry bread. 

The opium and bismuth mixture already given, increased in 
dose proportionately to the age, is very serviceable, or a combina- 
tion of aromatic syrup of rhubarb and chalk mixture may be used. 
As with infants, a course of wine of pepsin, or pepsin with muri- 
atic acid, should terminate the treatment. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 235 

7. CHRONIC INTESTINAL CATARRH- 
CHRONIC ENTERO-COLITIS. 

Chronic diarrhoea, as this condition is frequently termed, is a 
common and fatal disease in infants. When it occurs after the 
completion of the first dentition it is less dangerous to life, 
though it runs a protracted course and interferes greatly with 
nutrition. 

Morbid Anatomy. — As with other catarrhs, the absence of 
appreciable lesions is quite possible; but usually the mucous 
membrane of the colon is studded with minute, dark spots — the 
shaven-beard appearance — which the microscope shows to de- 
pend upon rings of vascular injection around the orifices of the 
follicles. In some instances there is deep congestion, limited 
principally to the summits of the longitudinal plicae, while in 
others, ulcers are also found. These ulcers are shallow, and either 
elongated and narrow, when they occupy the summits of the 
plicae, or small and circular, when they are seated between the 
folds. They are best seen by looking obliquely at the surface of 
the gut. Together with the ulcers there are numerous pearl-like 
projections, surrounded by narrow rings of congestion. These 
are enlarged solitary glands, and it is to their suppuration that 
the round ulcers are due. The whole mucous membrane is 
softened and thickened, unless the disease has been of very long 
duration, when it becomes extremely thin. The mesenteric glands 
are swollen and may even be caseous. In exceptional cases, 
the lower portion of the ileum presents the same changes as the 
large intestine. 

Etiology. — Entero-colitis, or a series of attacks of simple 
diarrhoea, may establish chronic diarrhoea ; but the disease fre- 
quently arises insidiously from the constant action of the great 
exciting cause — improper food. This cause is most operative in 
hand-fed infants, and at the time of weaning, but it affects nurs- 
lings who are supplied with poor breast-milk or allowed to eat 
bits of table food, and also older children. 

Exposure to wet and cold is another excitant ; so, too, are 



236 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

various acute diseases, notably measles, croupous pneumonia, 
typhoid fever, variola and scarlet fever. 

The predisposing agencies are bad hygienic surroundings, 
particularly over-crowding. In regard to age, the period of 
greatest liability as well as greatest fatality, is from birth to the 
end of the second year ; afterward it grows less common as age 
advances. In our climate the greater number of cases originate 
in early spring and autumn, when the weather is most change- 
able ; and late winter, when it is cold and damp. 

Symptoms. — The first indication of the disease is an alteration 
in the character of the stools. These assume the color and con- 
sistence of putty, and are composed of curd and farinaceous mat- 
ter, with semi-solid faeces, and, at times, mucus and streaks of 
blood. They are voided with much pain and straining, but are 
little, if at all, increased in frequency. Their odor is offensive 
and sour. The face is pale and listless in expression, though 
the child is sufficiently lively, takes his food well and has no 
fever. 

These symptoms continue with trifling change for two or more 
months, the patient gradually becoming thinner, paler and more 
languid. Then for the first time diarrhoea, sufficiently marked 
to arrest the nurse's attention, sets in. The evacuations now 
have a putrid odor, but vary considerably in other characters 
from day to day. They may be thin, liquid and brownish like 
dirty water ; or clay-colored, of the consistence of thin mud ; or 
watery, with particles of grass-green matter (from altered blood); 
and finally they may be slimy and contain whitish masses of undi- 
gested curd or particles of other food. The number of move- 
ments varies from ten to thirty in twenty-four hours ; their fre- 
quency depending upon the amount of food taken and, to some 
degree, upon the weather ; being greater on moist, cold days, 
than on warm, dry ones. They are preceded by pain, indicated 
by crying or uneasy movements of the legs, and are attended with 
straining, sometimes sufficient to cause prolapse of the rectum. 

The tongue is, usually, natural, though at times the tip and 
edges are too vividly red and the fungiform papillae too promi- 



AFFECTIONS OF THE STOMACH AND INTESTINES. 237 

nent. The appetite is normal, or even increased ; nevertheless 
wasting is continuous. The skin grows pale, dry and harsh, and 
assumes a peculiar earthy tinge, which is deepest over the ab- 
domen. The eyes are sunken and surrounded by dark circles ; 
the lips are bloodless and thin ; the nasal lines of Jadelot are 
marked, and the fontanelle is depressed. The abdomen may be 
soft and flaccid, but oftener is distended with flatus, and then is 
the seat of pain, manifested by moaning and twitching of the 
corners of the mouth. Palpation is painless unless there be ul- 
ceration ; in the latter case there is tenderness, and the contact 
of the hand causes borborygmus. The skin on the internal as- 
pect of the thighs and the nates is reddened by intertrigo, due to 
the irritant action of the faeces and urine. Prostration is so great 
that the child lies perfectly passive ; the pulse is feeble and fre- 
quent ; the temperature is not elevated, but, on the contrary, the 
hands and feet often feel cold, and have a bluish color. 

The urine is diminished in quantity and retained for long 
periods. 

With occasional brief intervals of improvement the condition 
gradually grows worse. The stools become more watery ; look 
like chopped spinach floating in brown, putrid water, and may 
contain mucus and pus with blood, in brownish-yellow masses. 
Abdominal distention, tenderness and gurgling, the signs of in- 
testinal ulceration, are present. The appetite is capricious or 
lost. The face becomes thin and pinched; the forehead is 
wrinkled ; the hair dry and lustreless, and the whole expression 
that of a puny, weak, old man. General wasting progresses until 
the body seems to consist of little more than the bones, which 
stand out prominently with the muddy, harsh, flaccid skin hang- 
ing from them in folds. To this emaciation the distended belly 
stands in marked contrast. The fontanelle, at this stage, is 
deeply depressed ; the pulse feeble ; the breathing superficial, 
and the temperature sub-normal, being sometimes as low as 
97. 5 F. in the rectum. 

As the end approaches, the nasal lines increase in depth ; the 
lips are red, fissured and encrusted with scales; the tongue dry, 



238 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

red and rasp-like from enlarged fungiform papillae, and the whole 
oral mucous membrane is covered with aphthae or thrush patches. 
A fetid odor hangs about the body. The feet and hands are cold, 
purple and cedematous. The little sufferer lies quiet, with half- 
shut, lustreless eyes ; from time to time an expression of pain flits 
over his face, but he is too weak to cry. Finally, there is no evi- 
dence of living, save the slow rise and fall of the chest as the 
breath comes and goes, and gradually this ceases, so gently that 
it is difficult to decide upon the exact moment at which life 
passes away. It is not uncommon for the discharges from the 
bowels to stop entirely for several days before the fatal termina- 
tion. This circumstance alone has no favorable significance. 

Death may result from exhaustion, or several complications 
may arise and hasten this event. These are serous effusions, 
hypostatic pneumonia, exanthemata, convulsions, and thrombosis 
of the cerebral sinuses. 

Serous effusion may take place into the pleurae, peritoneum and 
pericardium, but usually occurs in the form of oedema of the feet, 
hands, and, at times, the face. It is due to the impoverished 
condition of the blood and want of tonicity in the vascular walls. 

Hypostatic pneumonia , due to the constant dorsal decubitus, is 
a common cause of death. 

The exanthemata are very prone to attack the subjects of 
chronic diarrhoea, probably on account of the attendant prostra- 
tion reducing the power of resisting contagion. 

Convulsions are only dangerous in the early stages of the attack ; 
later, the nervous irritability is so blunted that this complication 
is rare. 

Thrombosis of the sinuses of the brain depends upon the with- 
drawal of the liquid elements from the blood by the diarrhoea. 
Water is then absorbed from the brain, lessening its bulk. The 
resulting vacuum, together with atmospheric pressure from with- 
out, leads to depression of the fontanelle, and even overlapping 
of the cranial bones in young subjects. If this be insufficient to 
compensate, the cerebral sinuses and blood vessels become en- 
gorged with blood, and as the naturally sluggish current in the 



AFFECTIONS OF THE STOMACH AND INTESTINES. 239 

sinuses is rendered more slow by inspissation of the blood and 
feebleness of the heart, the conditions for clotting are most 
favorable. At the autopsy, the clot is usually found in the longi- 
tudinal sinus, completely obliterating the channel ; it is laminated, 
whitish, and adherent to the walls of the sinus, which are free 
from signs of inflammation. The veins that enter the sinus are 
distended with blood. The symptons preceding death from this 
complication are difficult respiration; stupor; dilatation of the 
pupils and strabismus ; spasms of the posterior cervical muscles ; 
fulness of the jugular veins, and unilateral facial paralysis. 

When the case tends to recovery, the evacuations become more 
solid and natural in odor and color ; the latter change being 
caused by the reappearance of bile. The semi-stupor disappears, 
and the child grows very irritable, often crying out and shedding 
tears — a most favorable omen. The flesh, also, begins to return, 
the buttocks being the first part of the body to show the improve- 
ment. Diarrhoea is, after a time, succeeded by a constipated 
condition of the bowels. Convalescence is protracted. 

Children over two years of age, when affected with chronic 
diarrhoea, are pale, thin, languid and readily fatigued. Irrita- 
bility of temper, night terrors, and nocturnal incontinence of 
urine are common. The tongue is red at the tip and edges, with 
prominent papillae, and perhaps light frosting. The appetite may 
be normal, craving or capricious. The stools vary in number 
from three to twelve in twenty-four hours ; in the former case 
they are semi-solid, light colored, and mixed with minute masses 
of green or colorless mucus ; in the latter, they consist of dark 
liquid, containing lumps of clay-colored faeces ; this variation 
bears some relation to the state of the weather. The evacuations 
are always fetid in odor, and the act of defecation is attended 
by pain and straining. The abdomen is distended by flatus. 
Feebleness of the pulse is proportionate to the general weakness ; 
respiration is unaltered, and there is no pyrexia. 

In some instances the stools are limited to four or five a day, 
and are composed almost completely of undigested food and 
mucus. One evacuation occurs in the morning, soon after rising ; 



240 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the others during or immediately after meals. They are preceded 
by griping pain and by so urgent a desire, that the patient has 
difficulty in waiting for the chamber or reaching the closet. The 
condition undoubtedly depends upon great irritability of the 
intestine and exaggerated peristalsis. 

Diagnosis. — The diarrhoea of chronic catarrh is to be distin- 
guished from that of tuberculosis of the intestines ; the only 
condition with which it is likely to be confounded. Should it 
begin soon after birth or at weaning ; if there be a history of bad 
feeding or exposure, and if there be no constant elevation of 
temperature, the affection is probably catarrhal. A temporary 
rise in temperature may be caused by the eruption of teeth or 
other passing irritation, and is of no diagnostic importance. 

Tuberculous diarrhoea, on the contrary, occurs after the third 
year, and is attended by pyrexia and enlargement of the mesen- 
teric glands. On pressure there is tenderness and gurgling in 
the right iliac fossa, and tension of the abdominal wall over this 
region. There is also evidence of tuberculosis of the lungs. 
The evacuations, too, are distinctive ; they are intensely fetid, 
brown and liquid, when passed, but, on standing, deposit a dark 
sediment, composed of flocculent matter, with small, black clots 
of blood, and little masses of mucus, and pus. The presence, 
therefore, of these features or their absence, while the symptoms 
of catarrhal diarrhoea are observed, will determine the nature of 
the affection in. children who have passed the age of infancy. 

Prognosis. — Chronic intestinal catarrh is fraught with great 
danger when it attacks children under the age of two years. It 
is particularly fatal when it follows an acute disease ; when it 
occurs in syphilitic, rachitic or feeble subjects, and when it is 
complicated by measles or other exanthem. Unfavorable symp- 
toms are dryness and roughness of the tongue ; thrush ; anasarca ; 
features indicating intestinal ulceration, great depression of the 
fontanelle, and extreme emaciation. Favorable symptoms are 
normal progression of dentition ; the reappearance of tears ; in- 
termissions in the diarrhoea, and improvement in the character 
of the stools and general symptoms. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 241 

Treatment. — As the disease is produced by over-crowding, 
neglect, exposure, and unsuitable food, the initial measures of 
treatment must be the regulation of the hygiene, clothing and 
diet. 

The sleeping-room must be kept at a uniform temperature — 
between 64 and 68° F. — it must be dry, well-ventilated, and, if 
possible, heated, in cold weather, by an open wood-fire, and 
occupied by no one but the patient and nurse. During the day 
the patient must be moved to another room, being wrapped in a 
blanket if cold halls have to be passed. This room should be 
large, well-ventilated, dry, and kept at the same temperature as 
the first. After the removal, the windows of the sleeping-room 
should be opened, and the bed and its linen thoroughly aired 
and freshened. Soiled diapers or chambers containing stools are 
to be removed at once, and no cooking is to be done in either 
room. The child's person must be kept clean, and it is especially 
important to sponge the perineum and nates with warm water 
after each movement of the bowels ; and, if there be any red- 
ness of the skin, to anoint the parts with oxide of zinc ointment, 
or powder them. It may be impossible to carry out this plan 
among poor patients, but it can be approximated by keeping the 
baby clean, out of the kitchen and away from the door-step. 

As to clothing, the body must be clad in woolen from the 
neck to the toes, and, as an additional protection, a broad 
flannel, abdominal belt must be worn. So clothed, the patient 
may be taken into the open air on dry days, during the early 
stages of the attack. Soiled garments are to be replaced at once 
by fresh ones, and diapers must be washed when soiled ; not 
simply dried and used over again. 

The diet should vary with the age of the patient. The great 
principle being to maintain the general nutrition with the least 
amount of irritation of the intestinal mucous membrane. 

Infants partly nursed and partly bottle-fed do best when 
restricted to the breast, provided the latter be healthy. If the 
diarrhoea does not improve under the change, both the intervals 
and the time of nursing must be shortened. 



242 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

If the infant be hand-fed, every precaution must be taken to 
insure purity of food and perfect cleanliness of the feeding ap- 
paratus. The latter must consist of a simple bottle and tip, 
unless the amount to be given be very small, when a teaspoon 
can be used. The quantity of food and intervals of feeding 
always depend upon the degree of diarrhoea ; thus, in very severe 
cases, not more than a teaspoon fui every fifteen minutes can be 
allowed. The quality depends upon the age. 

For an infant under six months, cows' milk and lime-water, in 
the proportion of one part to two, or in equal quantities, may 
be tested. If this undergoes acid fermentation, fresh whey and 
veal or chicken broth, with equal quantities of barley-water, may 
be substituted. A teaspoonful of Mellin's food, dissolved in 
whey, barley-water, or diluted broth, makes an admirable food. 
At the age of six months, a good scale of diet when milk cannot 
be taken is: — 

First meal, 7 a.m. — One teaspoonful of Mellin's food dissolved 
in six ounces of veal broth and barley water, in equal parts. 

Second meal, 10 a.m. — One tablespoonful of cream in six 
ounces of freshly prepared whey. 

Third meal, 1 p.m. — Same as first, with chicken broth in place 
of veal broth. 

Fourth meal, 5 p.m. — Same as second. 

Fifth meal, 10 p.m. — Same as first. 

After a week or more of improvement, milk may be resumed 
gradually, in the beginning at the first meal only ; then at the 
first and last, and so on. 

Should these foods disagree, they must be discontinued and 
the child fed upon meat juice. This is prepared by chopping a 
piece of sirloin steak, free from fat or tendon, into small bits, 
and, after slightly warming, pressing out the juice with a lemon- 
squeezer. A teaspoonful, with a little salt, is to be given four 
times a day, and the quantity gradually increased as the peculiar 
fetid odor which it imparts to the stools disappears. 

After the age of six months, the yolk of a raw egg, well beaten 
with ten drops of brandy, a teaspoonful of cinnamon water, and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 243 

a little white sugar, may be administered once or twice a day, 
together with the milk, whey, or broth-food. 

After twelve months, if milk can be taken, the following diet 
is suitable : — 

First meal, 7 a.m. — Two teaspoonfuls of Mellin's food dis- 
solved in six ounces of milk and barley-water, equal parts. 

Second meal, 10 a.m. — Four ounces of veal broth with two 
ounces of barley-water. 

Third meal, 2 p.m. — The yolk of a raw egg, beaten up well 
with twenty drops of brandy, a teaspoonful of cinnamon water 
and a little white sugar. 

Fourth meal, 6 p.m. — Same as second, or four ounces of fresh 
whey with a tablespoonful of cream. 

Fifth meal, 10 p.m. — Same as first. 

It is most important to remember that if the evacuations be 
very frequent and watery, there can be no set meals, but the 
food must be given by the teaspoonful at intervals often or fifteen 
minutes. Also, that between set meals and these minimum 
quantities, there is a wide range in the amounts and intervals, 
according to the grade of the symptoms. 

From older children it is necessary to withhold potatoes and 
farinaceous vegetables generally ; fruits, sugar, sweetmeats, pastry, 
hot bread or cakes, butter and all made and highly-seasoned 
dishes; at the same time the bulk of each meal must be some- 
what restricted. A good diet is : — 

For breakfast, at 7.30 a.m. — One or two tumblerfuls of milk 
warmed and diluted by the addition of a fourth part of hot 
water ; the yolk of a soft-boiled egg, salted, and a slice of thin, 
dry toast. 

For luncheon, at 12 m. — The soft parts of eight raw oysters, 
flavored by lemon juice, and a Boston cracker. Or in summer 
a small teacupful of junket, with a cracker. 

For dinner, at 3 p.m. — A bit of the breast of chicken cut up 
very fine, or a tender piece of roast beef or beef-steak treated in 
the same way; with a tablespoonful of well-boiled spinach, 



244 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

asparagus tops, cauliflower tops, or stewed celery, and a thin 
slice of dry, stale bread. 

For supper, at 7 p.m. — A glass of milk, warmed as at break- 
fast, and a slice of well-made cream toast. 

An important rule in all cases is to watch the diet carefully 
until all danger of a relapse has passed. 

Baths and external applications are useful. Infants who are 
not much prostrated should be placed in a hot bath (95°-ioo° 
F.) every evening for three minutes, then quickly dried, an- 
ointed over the whole body with warm olive oil, wrapped in a 
blanket and put to bed. If there be much prostration, the bath 
must contain mustard, one teaspoonful to the gallon, and the 
child kept in until the supporting arms of the nurse begin to 
tingle. 

When intestinal ulceration is suspected, the belly should be 
enveloped in a light flax-seed poultice, or, what answers as well, 
a layer of carded cotton covered with oiled silk. 

Medicines are to be selected according to the stage of the 
attack. Early, while the stools are little increased in number, 
but putty-like and of sour odor, the bowels must be gently acted 
on by : — 

R . Pulv. Rhei, , gr. vj. 

Sodii Bicarbonatis, gr. xij. 

M. et ft. chart. No. vj. 

S. — One powder three times daily, for an infant of three to 
six months. 

Afterwards — on the succeeding day, usually — the following 
powder may be administered : — 

R. Pulv. Ipecacuanhas Comp., gr. iv. 

Cretse Praeparatse, gr. xxxvj. 

M. et ft. chart. No. xij. 

S. — One powder every four hours. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 245 

Or often better :. — 

R. Tr. Opii Deod., TT\vj. 

Sodii Bicarb., , . gr. xlviij. 

Syrupi, f Jss. 

Aquae Menthae Pip., q. s. adfgiij. 

M. 
S. — One teaspoonful every four hours. 

When the stools become frequent and green, the mixture of 
opium, bismuth and chalk, already given (page 234), is very 
useful ; and if tenesmus be very severe, a sedative enema must 
be used, as: — 

R. Tr. Opii, gtt. iij. 

Potass. Bicarb., gr. iij. 

Mucilag. Amyli., . f§ ss ' 

M. 
S. — To be injected into rectum. 

This may be repeated every six or twelve hours, according to 
the necessity, taking care that the child — and all children are 
very susceptible — does not get too much opium. 

Should the diarrhoea still continue, and the stools become 
watery and very fetid, astringents are required ; for example : — 

R. Acid. Sulphurici Aromat., n\xxiv. 

Liquor. Morphias Sulph., f 3 ij. 

Elix. Curacoae, fS ss * 

Aquae, q. s. ad f J iij. 

M. 

S. — One teaspoonful every three hours. 

Or— 

R . Argenti Nitratis, . . - gr.ss. 

Syr. Acaciae, fgss. 

Aquas, q. s. ad f^ iij. 

M. 

S. — One teaspoonful every three hours, midway between 
meals, if possible. 

Nitrate of silver is most valuable when the stools contain mucus 



246 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and blood, and aphthae or thrush are present. It may be also 
used as an injection, if there be evidences of ulceration, 
thus: — 

R . Argenti Nitratis, gr.j. 

Aquae, fgj. 

M. 
S. — Inject once or twice daily after cleaning out the rectum 
with an injection of warm water. 

These injections must be suspended for twenty-four hours after 
being continued for three days. 

Prostration and depression of the fontanelle demand stimulants. 
Ten drops of whiskey in water every two hours is about the 
average dose, but it may be given oftener and in larger quantities 
as circumstances require. 

As soon as the stools become normal in character and fre- 
quency, the child must be ordered tonics, as :— 

U . Liquor. Ferri Nitratis, rr\,xxiv. 

Glycerinae, fgss. 

Aq. Menthse Pip., q. s. adfgiij. 

M. 
S. — One teaspoonful three times daily. 

Or— 

1J . Ferri et Ammonii Citratis, gr.xij. 

Tr. Gentianae Comp., . . fgj. 

Spt. Lavandulae Comp., f ^ ij. 

Syrupi Limonis, q. s. ad f% iij. 

M. 
S. — One teaspoonful three times daily. 

For the constipation of convalescence very small doses of castor 
oil — twenty drops — may be ordered once or twice daily, but it 
is best not to interfere unless the bowels have been indolent for 
twenty-four or forty-eight hours. 

With older children the medical treatment is more simple. 
Ordinarily, either of the following prescriptions will suffice : — 



AFFECTIONS OF THE STOMACH AND INTESTINES. 247 

R. Syr. Rhei Aromat, -. . . . f^vj. 

Sodii Bicarbonatis, f 3 ij. 

Tr. Opii Deod., n\,xxxvj. 

Aq. Menthae Pip., . q. s. adfgiij. 

' M. 

S. — One teaspoonful every three hours, for a child from four 
to six years. 

Or if the diarrhoea resist : — 

R. Tr. Krameriae, f^pij* 

Tr. Opii Camphoratae, * f g ij. 

Spt. Lavandulae Comp. , f ^ ij. 

Misturae Cretae, q. s. adfgiij. 

M. 

S. — Two teaspoon fuls every three hours. 

The lienteric form of diarrhoea should not be treated by 
astringents but by nux vomica followed by arsenic. For in- 
stance, until the stools become less frequent and urgent and the 
griping pain diminishes, a good prescription is : — 

R. Tr. Opii Deod., 

Tr. Nucis Vomicae, aa TT^xlviij. 

Aq. Menthae Pip., q. s.adf^iij. 

M. 
S. — One teaspoonful before each meal, at the age of six 

years. 

Afterward : — 

R. Liq. Potassii Arsenitis, fgj. 

Inf. Gentianae Comp., q. s. adf^iij. 

M. 
S. — One teaspoonful after each meal. 

Washing out the intestine is also a useful method of treatment : 
this will be fully described in the next section (Entero-colitis). 

During convalescence from chronic diarrhoea, older children 
do well upon the same tonics as infants, the doses being propor- 
tionately increased. 



248 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

8. ENTERO-COLITIS. 

{Summer Diarrhoea — Febrile Diarrhoea.*) 

Entero-colitis, or inflammatory diarrhoea, is the scourge of our 
large cities during the summer months, when it brings death to 
hundreds of children, especially among the over-crowded, ill-fed 
poor. To it is due the popular dread of that period of an infant's 
life termed " the second summer/' and justly, for among those un- 
fortunates who are obliged to pass this time in crowded houses, 
and narrow, filthy streets, the instances of complete escape are 
very rare. 

Morbid Anatomy. — The anatomical lesions consist in inflam- 
matory hyperaemia of the intestinal mucous membrane. This 
may be distributed over the whole tract, but commonly it is 
limited to the ileum and colon, and is most intense in the neigh- 
borhood of the ileo-caecal valve and the sigmoid flexure. The 
mucous membrane is reddened, swollen and softened. Redness 
is either general or in the form of arborescent patches about the 
follicles; while swelling and softening are proportionate to the 
degree of congestion. The former is sometimes so great at the 
lower end of the ileum as almost to occlude the valve ; to this 
has been attributed the vomiting which, in the absence of gastric 
lesions, is otherwise difficult to explain. The isolated glands are 
enlarged, and more opaque than normal, having the appearance 
of grains of white sand scattered over the mucous surface, and 
the Peyer's patches are tumefied and projecting, with punctated 
surfaces. On the peritoneal aspect, the gut, in positions corres- 
ponding to the inflamed glands, presents areas of arborescent in- 
jection. There is moderate enlargement of the mesenteric glands. 

From this condition it is but a step to the state of ulceration 
seen in chronic intestinal catarrh — a not infrequent result of 
entero-colitis. 

The stomach, as already hinted, is usually normal in appear- 
ance ; occasionally its mucous membrane is reddened and 
thickened, and it is quite possible that this viscus is often the 



AFFECTIONS OF THE STOMACH AND INTESTINES. 249 

seat of a catarrh so moderate in degree as to leave no evidences 
after death, though sufficient to give rise to vomiting during 
life. 

Etiology. — Season, age and locality of residence are impor- 
tant factors in the causation. Only isolated cases occur in the 
winter months, and these are met with among the poor, with 
whom it is a habit, for convenience in watching, to keep 
infants in the living room, which is also the kitchen ; this is 
heated by the cooking-stove, and is either intensely hot when 
the room-door is closed, or too cold when it is left open, in the 
frequent excursions of the older members of the family to the 
yard or street. There is, therefore, a constant exposure to sudden 
and marked changes in temperature. At the same time the air of 
such a room is contaminated by cooking, by re-breathing, and by 
the exhalations from soiled clothing and dirty bodies. These are 
sufficient causes for an attack of entero-colitis. About the middle 
of May or June, according to the character of the individual 
season, cases become more common, and as the summer heats are 
established, in July, August, and the first half of September, the 
number is augumented to the proportions of an epidemic. Late 
in September or in October, according, again, to the season, 
there is a marked diminution, and this increases as winter 
approaches. During the summer the number of cases and deaths 
varies with the range of the thermometer ; several successive 
days with a temperature above 90 F. being attended by a 
great increase, while a similar period with a temperature below 
8o° is followed by a decided decrease. Hot, damp weather is 
the most productive, and of all months August is the most fatal, 
both on this account and because a high temperature is main- 
tained during the night. 

Infants between the ages of six and eighteen months are by 
far the commonest sufferers. Their liability depends upon the 
sympathetic irritation of the alimentary tract attending the 
cutting of the teeth ; the increased tendency to inflammation 
produced by the rapid development that the intestinal glands 
and follicles are simultaneously undergoing, and the fact that 
21 



250 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

weaning, with its consequent change of diet, usually takes place 
during this interval. From the eighteenth month to the end of 
the second year, about one-fourth as many cases occur, and the 
third period of greatest frequency is from birth to the sixth 
month. Children over three years are not often attacked. 

Residence in large cities is almost an essential etiological con- 
dition ; the vast majority of cases occur where the streets are 
narrow and more than ordinarily filthy, and where the houses 
are overcrowded and dirty, and the people poor, ill-fed and un- 
clean. There must be another factor at work here besides the 
elevated temperature, since in the open country immediately 
surrounding affected cities, where the thermometer ranges nearly 
as high, the disease is of exceptional occurrence. This factor is 
an atmosphere polluted by poisonous gases and containing count- 
less bacteria, the result of decomposing organic substances. 

Another potent agent is bad food. Infants, hand-fed from 
birth, are the most frequent sufferers ; next, those who are weaned 
early; in both, the chief injurious articles of diet are sour milk, 
farinaceous preparations in excess, and "tastes" of table-food. 
Nursing infants are more exempt, but even with them, too 
frequent and continuous feeding, or breast-milk of abnormal 
quality, when other conditions are unfavorable, often produce 
entero-colitis. 

Symptoms. — For one or two days prior to the actual attack, 
the infant is restless and fretful ; his sleep is disturbed by moan- 
ing or fits of crying; he is paler than usual, and his head and, 
perhaps, the palms of his hands, feel hot. He also ceases to 
empty his bottles ; after feeding, eructations of very sour-smell- 
ing material are apt to occur, and the stools are somewhat more 
numerous and softer than usual. 

Next, vomiting and diarrhoea set in. The former occurs after 
feeding, and, in bad cases, is so obstinate that nothing is re- 
tained. The matter rejected consists of sour, acid and curdled 
milk, or other food imperfectly digested. 

The stools range from six to twenty or more in twenty-four 
hours, and vary in character from day to day, and even from 



AFFECTIONS OF THE STOMACH AND INTESTINES. 251 

hour to hour. At first, they are semi-solid, homogeneous, yellow 
in color and neutral in reaction ; then they become more liquid 
and green, though still homogeneous and neutral, and then the 
reaction becomes acid without change in the other characters. 
Often they are semi-fluid, heterogeneous, green with little masses 
of yellow faeces, and neutral ; or semi-fluid, heterogeneous and 
green, with fragments of yellowish-white caseine and acid ; or 
watery, with floating flakes of white, yellow or green matter, and 
acid. Mucus and blood may be mixed with any of these stools ; 
the first in stringy masses ; the second, in bright red streaks or 
merely tingeing the mucus. In severe cases the passages become 
watery and so colorless as hardly to stain the diapers. The odor 
at first is faecal, then sour, and finally offensive. The act of 
defecation is preceded by pain, manifested by the expression of 
the face, by crying, and by twisting of the trunk and drawing 
up of the legs. Sometimes there is tenesmus and slight prolapse 
of the rectum ; it is under these circumstances that blood appears 
in the stools. 

The tongue is dry, red at the tip and edges and covered in 
the centre with a light white coating ; the appetite is diminished 
and the thirst increased. The abdomen is distended by flatus, 
and, at times, there is tenderness on pressure. 

With these features there is pyrexia, moderately high and con- 
tinuous for the first three or four days, afterward remittent ; the 
head is especially hot, and the palms of the hands are dry and 
burning to the touch. The pulse is weak and frequent, beating 
120, or even 140 times per minute. The urine is reduced in 
quantity and passed at long intervals, sometimes only two or 
three times a day. 

As the diarrhoea continues the face becomes pale ; the eyes are 
surrounded by dark circles ; the nasal lines appear ; the fon- 
tanelle, if still membranous, is depressed ; the fat disappears 
from the body ; the muscles grow soft and flabby ; the buttocks 
and inner surfaces of the thighs are reddened by the acid stools 
and concentrated urine, and there is great feebleness and languor. 
In grave attacks these changes take place in an incredibly short 



252 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

space of time, twenty-four hours being ample to reduce an active, 
robust infant to a mere shadow of himself. 

If death approach, the patient, in some cases, grows fretful ; 
has a dry, burning skin ; rolls the head from side to side ; vomits 
incessantly ; has strabismus and indolent pupils, and may have 
convulsions, which are more frequently unilateral than general. 
In others, there is drowsiness, an apathetic refusal of food, ces- 
sation of vomiting and diarrhoea, and coolness of the extremities. 
This difference depends upon the acuteness of the attack, for 
upon this rests the preservation or loss of nervous irritability. 

The great diminution of the urinary excretion suggests the 
possibility of the fatal termination being, in some instances, due 
to ursemic poisoning. 

When the attack tends to recovery the vomiting stops ; the 
motions are less numerous and more faecal ; the skin becomes 
cooler and more moist ; the urine is excreted freely ; the eyes 
grow bright ; the child again shows interest in his surroundings ; 
takes his food better, and rapidly regains flesh and strength. 

Diagnosis. — The pyrexia, the vomiting, and the frequency 
and character of the stools, taken in conjunction with the early 
age of the patient; the season and locality of occurrence; and 
the almost epidemic prevalence of the disease, make its dis- 
tinction an easy matter. The portion of the intestinal canal 
chiefly involved is not so readily determined, though the presence 
of mucus and blood in the evacuations points to the colon as the 
seat of inflammation; their absence, by inference, to the small 
intestine. It is important to differentiate this disease from 
cholera infantum, which is an infinitely more serious disease. 
Cholera infantum is sudden in its onset, characterized by a high 
temperature, from 105 F. to 108 F., uncontrollable vomiting; 
frequent and profuse serous evacuations ; embarrassed respiration ; 
frequent and irregular pulse ; marked involvement of the nervous 
system, and rapid collapse. Often a case will pass in the course 
of twenty-four hours from blooming health into a condition of 
almost ante-mortem decomposition. We do not see these changes 
in entero-colitis. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 253 

Prognosis. — Inflammatory diarrhoea ranks among the most 
dangerous of the affections of infancy, both from its inherent 
nature and its tendency to run into chronic entero-colitis. 
Nevertheless, under appropriate management, a large proportion 
of cases recover. The outlook is most discouraging when the 
infant's lot has been cast in poverty ; when it has been hand-fed 
from, or soon after birth ; and when it has had the bad fortune 
to be born in the late winter or spring, so that weaning and the 
time of cutting the more troublesome teeth come together in the 
second summer. 

The unfavorable features are high fever, very frequent and 
watery evacuations, rapid collapse, cerebral symptoms and con- 
vulsions. 

An attack may prove fatal in four or five days, or it may be 
protracted for two weeks. The latter is about the duration of 
severe cases that terminate in recovery. One attack predisposes 
to another, an important point to remember in the treatment by 
change of climate. 

Treatment. — People with means avoid the dangers of summer 
diarrhoea by taking their children to the country, sea-shore or 
mountains, where the air is uncontaminated, the heat less in- 
tense and the milk pure. Such escape is not open to the children 
of the poor ; nevertheless, much may be done to preserve their 
health by keeping them during the day in the fresh air of public 
parks ; by bathing in cool water ; by proper, cleanly clothing ; 
good food — for good milk is as cheap as bad — and by attention 
to the cleanliness of beds and sleeping rooms. This the parents 
can, and in many cases will do, and if they would only secure 
well-paved and decently clean streets — for it is impossible to 
clean ill-paved ones — entero-colitis would become a far less com- 
mon disease. 

When an attack occurs during the hot months, the patient, if 
possible, must be sent at once from the city to the sea-side or 
country. The locality selected should be near at hand, or the 
journey will be too fatiguing ; still, it is important to fix upon a 
place affording a decided change of air and a lower temperature. 



254 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

From Philadelphia the infant may be taken to Atlantic City, 
Cape May, Point Pleasant, Avon or any of the many resorts on 
the Jersey coast, kept there for two or three weeks and then 
removed to the New Hampshire hills for the remainder of the 
summer. A long stay is essential, since a return to town in hot 
weather is almost certain to be followed by a relapse. 

If circumstances render it impossible to carry out this most 
potent of all prescriptions, fresh air must be secured by taking 
the child to the public squares in the cool of the morning and 
evening, or by spending the day in the Park, or, better still, by 
a morning and evening trip on one of the river steamboats. 
The heat of the day must be spent in as cool a room as can be 
had. It is of great moment to let the little sufferer rest in bed 
and not on the hot lap or shoulder, and when out, to wheel him 
in a coach rather than carry him. Many a stout mother has 
hastened her infant's death by too fond and constant nursing. 

The clothing must be as thin as possible, provided, always, 
that woolen be worn next the skin. 

Twice or three times a day, in very hot weather, the whole 
surface of the body should be sponged with water at a tempera- 
ture of 8o° F., and dried with gentle rubbing. The bracing 
effect of these baths is greatly increased by the addition of rock 
salt, or concentrated sea-water if the purse can afford it. These 
cool spongings must be supplanted by full warm baths when there 
is much prostration. 

In regulating the diet, it must be remembered that the pres- 
ence of fever, with increased thirst, leads the child to take more 
liquid food than is needed or can be digested ; consequently, it 
is necessary to specify the quantity as well as the quality of the 
food. Infants at the breast are to be suckled only at intervals 
of two or three hours, according to their age, and taken away 
before they have completely satisfied themselves. 

Hand-fed babies are to be similarly restricted. As cows' milk 
must constitute the bulk of their food, it is important to see that 
it is obtained fresh every day from a reliable dealer, promptly 



AFFECTIONS OF THE STOMACH AND INTESTINES. 255 

sterilized, and administered from an absolutely clean bottle fitted 
with a simple tip. For example : — 

Milk, fgiij. 

Cream, f2 ss# 

Lime-water, f Jijss. 

Sugar of milk, 5J. 

Mix in a clean tin-cup, pour into bottle, adjust tip, and warm 
by plunging into hot water. 

Milk, fjiij. 

Cream, f § ss. 

Mellin's Food, 3 ij. 

Hot water, f3y ss * 

Dissolve the Mellin's food in the hot water, add the milk and 
cream, and, if necessary, warm as before. 

Milk, f|iij. 

Cream, . . . . f^ss. 

Flour-ball, gj. 

Water, ...>■' ':,; fgijss. 

Either one of these foods may be given every three hours to a 
child of ten or twelve months old. The quantity is less and the 
dilution greater than for a healthy infant of the same age, because 
enfeebled digestion demands a proportionate reduction in the 
amount and strength of the food. 

When preparations of milk are vomited or passed undigested 
from the bowels, a whey mixture or strippings can be resorted 
to, and if these fail, beef-juice, or — 

Flour-ball, 3 ij. 

Water, f J vj. 

Mix, and add — 

Half the white of a fresh egg. 

Bits of ice and cool filtered water can be allowed, in modera- 
tion, to relieve the thirst. 

If vomiting be persistent, all food must be stopped for from 
twelve to twenty-four hours, and the thirst quenched by thin 



256 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

barley-gruel or Vichy water, — cold, and in small quantities. 
If the child be at the breast, as soon as vomiting is checked, it 
can gradually be brought back to its accustomed diet, care being 
taken that too much food be not taken. In bottle-fed children 
under two years, it is better to withhold milk entirely ; wine- 
whey, chicken and mutton broth, Mellin's food with barley- 
gruel, the juice expressed from raw beefsteak or roast beef, and 
sometimes raw-scraped beef, should constitute the " no-milk 
diet." 

The indications for medical treatment may be grouped under 
four heads: 1. To clear out the bowels ; 2. To stop decomposi- 
tion ; 3. To restore healthy action in the alimentary tract ; 
4. To treat the consecutive lesions. 

1. The bowels should be emptied as completely as possible, 
as the first step in the treatment, and for precisely the same 
reasons that the surgeon cleanses a wound thoroughly before ap- 
plying antiseptic dressing. This rule holds good not only where 
there is a history of antecedent constipation, or the evidence of 
the presence of indigestible food in the alimentary tract, but in 
every case in which there are altered secretions undergoing pu- 
trefactive changes. The only instances in which the process of 
cleansing should not be undertaken, because unnecessary, are 
those where, after two or three fecal or semi-fecal evacuations, 
the discharges consist of almost pure serum, large in amount, 
alkaline in reaction, and odorless. 

To sweep out the intestinal canal nothing compares in effi- 
cacy with castor-oil. Should the stomach be very irritable, 
however, it will be necessary to substitute enemata. These should 
consist of pure water at a temperature of 65 ° Fah., and to be effi- 
cient must be copious enough to reach the caecal valve, — about 
one pint in a child of six months, and two pints in one of two 
years. The injection must be given slowly, with a fountain 
syringe, the abdomen meanwhile being gently manipulated. 

Many mild cases can be cured, if taken at the start, by castor- 
oil and a strict diet alone. 

2 and 3. To stop decomposition and restore a healthy action 



AFFECTIONS OF THE STOMACH AND INTESTINES. 257 

in the intestines, the administration of antiseptics and attention 
to diet are necessary. 

Antiseptics must be given in small doses lest the stomach re- 
ject them, and frequently to maintain a continuous action. The 
best are calomel, salicylate of sodium and naphthalin. 

Calomel may be prescribed in the following combination : — 

R . Hydrargyri Chloridi Mit., gr. j£. 

Bismuthi Subcarbonatis, gr. xxxvj. 

Pulv. Aromatici, ........... gr. vj. 

M. 

Et ft. chart. No. xij. 
S. — One powder every two hours. 

Salicylate of sodium is prescribed in doses of from one to 
three grains every two hours, according to the age, from three 
months to three years. An aqueous solution is tasteless, and can 
readily be given in the food or drink; it has a tendency to 
check rather than occasion vomiting. It may also be substi- 
tuted for the calomel in the above prescription. 

Naphthalin, although possessing a strong odor, is not disagree- 
able to the taste. On account of its insolubility, it is best ad- 
ministered rubbed up with some moist powder, like sugar of milk. 
The doses should be larger than those of the salicylate of 
sodium, — one to five grains, according to the age. 

Resorcin and bichloride of mercury are also useful antiseptics. 
Resorcin is bitter, and though freely soluble in water, not easily 
administered ; the dose is one-half a grain to two grains. The 
bichloride is given in doses of yi^ to T ^ of a grain, but even in 
these minute quantities frequently causes vomiting. 

Counter-irritation by mustard plasters to the belly is useful. 
Stimulants are required when prostration sets in, and must be 
given in doses and at intervals adapted to the demands of the 
case. 

Applications of oxide of zinc ointment, with cleanliness, cure 
the intertrigo of the buttocks and thighs most quickly, or, at 
least, keep it in check until the cause is removed. 

4. The essential consecutive lesions are in the colon, and 
22 



258 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

consist practically of a follicular colitis. When the condition of 
ulceration is reached, astringents by the mouth are useless, with 
the possible exception of bismuth. 

Three things are valuable :— 

First. As careful attention to the diet as during the acute 
stages, and in recent cases. Deviation from dietetic rules is the 
most frequent cause of relapse. 

Second. The continuance of antiseptics to check intestinal 
decomposition, and hence stop irritation. 

Third. The whole large intestine should be washed out once 
every day, either with pure water at 65 ° F., or with weak anti- 
septic or astringent solutions. Of the former the best are ben- 
zoate or salicylate of sodium ; of the latter, nitrate of silver or 
tannic acid. 

Attention to diet and hygiene is not to be relaxed when con- 
valescence is established, and after the measures calculated to 
check diarrhoea are unnecessary, digestants, as wine of pepsin, and 
tonics, as the ferrated elixir of cinchona, are still required, to 
restore health. 

The exceptional cases that occur in cold weather should, of 
course, be treated at home in a well-ventilated and warm room ; 
otherwise, the only alteration to be made in the general plan of 
management is to envelop the abdomen with light linseed poul- 
tices, or with cotton covered by oiled silk. 



9. CHOLERA INFANTUM. 

This affection occurs in teething children during hot weather, 
and is characterized by a sudden onset, high fever, irritability of 
the stomach, frequent serous evacuations, changes in the respira- 
tion and pulse, marked symptoms of nerve involvement, and 
rapid collapse. It is a far less common disease than entero- 
colitis, and is the analogue of cholera morbus in the adult. 

Morbid Anatomy. — In cases that run the ordinary course and 
die early, the gastro-intestinal mucous membrane is congested, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 259 

thickened and softened, and the follicles and Peyer's patches are 
enlarged. In other words, the appearances indicate the early 
stage of inflammation, which passes into lesions identical with 
those of entero-colitis, when the patient, as sometimes happens, 
survives the choleraic stage and dies, subsequently, from a more 
protracted diarrhoea. But, in addition to inflammation, there is 
probably — and this is the important point — some involvement of 
the sympathetic nerves, leading to dilatation of the capillaries and 
transudation of serum into the intestine, and to alterations in 
the pulse, temperature, respiration and urinary excretion. The 
nature of this is paralytic, so far as the intestine is concerned, 
and resembles in its results experimental section of the sympa- 
thetic nerves. It is due, in part, to direct over-stimulation by 
the irritant contents of the canal, and in part to the nerve 
exhaustion produced by high atmospheric temperature, one of the 
essential causes of cholera infantum. The changes in calorifica- 
tion and in the functions of the heart, lungs, and kidneys, de- 
pend upon reflected irritation, and also, perhaps, upon the 
depressing effects of heat on the governing nerve centres. 

Etiology. — Like entero-colitis, this is a disease of cities, find- 
ing its victims chiefly among those who live in poverty and 
squalor. Almost exclusively confined to hot weather, it may 
occur at any time between the middle of May and the end of 
September, though the greater proportion of cases originate 
during the latter half of July, August, and the first half of Sep- 
tember. Infants from six to twelve months are the most suscep- 
tible subjects ; it may, however, occur at any age up to two years. 
The susceptibility of the former age is due to the great functional 
activity of the intestinal mucous membrane and the rapid devel- 
opment of the follicles that accompany dentition, rather than the 
mere act of cutting teeth. The direct causes are high temperature 
(^5°~95° F. or more) sustained for several days, and especially 
if associated with a moist atmosphere, exposure to an atmosphere 
rendered impure by noxious gases and bacilli generated from 
filth by heat, impure water and bad food. 

Symptoms. — An attack may arise in the midst of health, or it 



260 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

may be preceded by diarrhoea. In either case the onset is sudden. 
The infant begins to void copious stools. These at first, if there 
has been no premonitory diarrhoea, contain more or less faecal 
matter, but they soon become watery. Sometimes they are so 
serous as to soak away into the diaper without leaving any stain ; 
at others, they contain a few yellow or green flocculi or little 
masses of mucus, and, in both instances, are odorless. Again, 
they are composed of yellow or brown liquid, containing a small 
proportion of thin, faecal matter, and have a peculiar musty and 
offensive odor, which clings to the napkins and clothing, and 
even to the body of the child, in spite of the utmost efforts at 
cleanliness. The number varies from eight to thirty in twenty- 
four hours, and they are evacuated with considerable force. 

At the same time, or soon after, the stomach becomes so irri- 
table that everything, even to a mouthful of ice-water, is rejected 
as soon as swallowed, and there is violent retching. Appetite is 
lost, but there is intense thirst, the patient eagerly drinking when 
the opportunity offers, and following the glass, as it is removed, 
with greedy eyes. The tongue, originally moist and lightly 
frosted, soon becomes dry and pasty, and protrudes from the 
parched lips. The abdomen is flaccid and indolent. 

There is great restlessness; the temperature is elevated to 105 
or even 108 F. ; the pulse is small and very frequent, counting 
from 130 to 150 beats per minute ; the breathing becomes 
irregular and anxious, and the urine is greatly diminished in 
quantity. 

With these symptoms there is a marked and appalling change 
in appearance. Within a few hours, the infant, perhaps plump 
and rosy before, can scarcely be recognized ; the face becomes 
pale and pinched \ the eyes and cheeks sunken, and the eyelids 
and lips permanently parted from loss of muscular contractility ; 
the fat melts from the body ; the muscles, grow flabby ; the bones 
appear prominent, and the skin, often greenish or cadaverous in 
hue, hangs in loose folds. 

Soon the features of collapse appear. The hands, feet, nose, 
and even the breath, become cool, the pulse is thready and so 



AFFECTIONS OF THE STOMACH AND INTESTINES. 26 1 

frequent as to be uncountable ; the respiratory movements are 
more unequal, and there is drowsiness, apathy, and suppression 
of urine. As life ebbs away, the vomiting stops ; the surface 
becomes cold and clammy ; the face is set with the lines of death; 
the respiration is quickened and shallow ; the pulse scarcely per- 
ceptible, and the patient sinks into a state of semi-coma, with 
bleared eyes and contracted pupils. In this condition the end 
may come quietly or be preceded by slight convulsions. 

The course of the disease, whatever the result, is always very 
short. It may prove fatal in from one to four days, or the 
character of the attack may change and death result later from a 
secondary inflammatory diarrhoea. 

In case of recovery, the stools, after four or five days, gradually 
become less copious, frequent and watery, more faecal and of 
better odor ; vomiting stops ; thirst diminishes ; appetite returns ; 
the urinary excretion is reestablished ; the temperature and pulse 
fall; the respiratory movements become rhythmical ; emaciation 
ceases, and the child, though very feeble, again notices his sur- 
roundings, and after a week or more of simple diarrhoea, regains 
a moderate degree of health. 

Diagnosis. — The character of the stools, the extreme irrita- 
bility of the stomach ; disturbed respiratory rhythm ; high 
temperature ; intense thirst and rapid emaciation and collapse, 
distinguish this from entero-colitis, and from other forms of 
diarrhoea. 

There is a certain resemblance between cholera infantum and 
sunstroke, and, by some, the two conditions have been considered 
as identical. The forms of similarity, as well as those of dis- 
similarity, may be seen in the following table : — 

CHOLERA INFANTUM. SUNSTROKE. 

Temperature 105 to 108 F. Temperature often 108 F. 

Pupils contracted. Pupils contracted. 

Evacuations watery. Evacuations watery. 

Respiration embarrassed. Respiration embarrassed. 

Urine scanty. Urine scanty. 



262 



DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 



CHOLERA INFANTUM. 

Cerebral symptoms marked, but 
secondary 

Gastro-intestinal symptoms, prece- 
dent and prominent. 

Onset rapid. 

Preceded by diarrhoea or uncomfor- 
table sensations. 

Restlessness at onset. 

Occurs at any time of day or night. 

Inflammatory lesions of intestines. 



SUNSTROKE. 

Cerebral symptoms marked, but 
primary. 

Gastro-intestinal symptoms, secon- 
dary 

Onset sudden, by a stroke. 

No such previous history. 

Stupor from beginning. 

Occurs only during excessive heat 

of day. 
No such lesions. 



Between epidemic cholera and cholera infantum it is impos- 
sible to make a diagnosis. 

Prognosis. — The prospect is most discouraging, and even in 
seemingly favorable instances the opinion as to the result must 
be guarded, for though the choleriform symptoms be survived, 
there is danger from the succeeding diarrhoea. The disease is 
most fatal in children of the poor, who are badly fed and sub- 
jected to the worst hygienic influences; conversely, it is more 
apt to terminate in recovery in the rich, who can be treated in 
large, airy rooms, fed on good food, and removed to healthy 
localities. 

Treatment. — The large and frequent watery evacuations are 
such a strain upon the system, that it is of the first consequence 
to replace the waste by food and drink, and at the same time 
check it by appropriate treatment. 

The irritability of the stomach is a formidable barrier to 
alimentation ; nevertheless, every effort must be made to give 
food in small quantities and at short intervals. Should the infant 
be at the breast, it may be allowed to nurse for a few minutes, 
every half-hour or hour. If hand-fed, it may be given the same 
foods recommended for entero-colitis, or chronic vomiting, in 
such quantities as can be retained, and at intervals corresponding 
in frequency to the smallness of the amount. Bits of ice and 
water should be allowed freely, even though they be rejected as 
soon as swallowed. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 263 

To check the diarrhoea opium and astringents are necessary. 
A very serviceable formula is : — 

R. Liquor. Morphiae Sulph., f^j. 

Acid. Sulphurici Aromat., rr^xxiv. 

Elix. Curacoae, f,? ss * 

Aquae, q. s. ad fgiij. 

M. 
S. — One teaspoonful every two hours, for a child of six 

months old. 

With this, two drops of laudanum, suspended in two teaspoon- 
fuls of starch-water, should be administered, by the rectum, 
every three hours. Two or three times daily a mustard plaster 
(one part of mustard to five of flour) must be applied over the 
whole surface of the abdomen, long enough to redden the skin, 
and the whole body should be sponged several times a day with 
water at a temperature of 95 ° F. 

The clothing, diapers and person must be kept perfectly clean ; 
the sick-room must be as large and airy as can be commanded, 
and the infant must lie upon abed, and not be constantly nursed 
upon the lap. If it be possible, the patient should be sent early 
to the sea-shore or country, as this affords by far the best chance 
for recovery. Failing in this, morning and evening airings in a 
coach, or daily steamboat excursions, must be resorted to. 

Stimulants are needed from the first to ward off prostration. 
From five to ten drops of whiskey in a teaspoonful of lime-water 
may be given every two or three hours at the age of six months. 

When collapse sets in, the quantity of alcohol must be increased, 
and, if the stomach can bear it, a combination of stimulants is 
useful, as : — 

R. Spt. Frumenti, f^ ss - 

Ammonii Carbonatis, gr. xxiv. 

Syrupi Acacise, fgj. 

Aq. Menth. Pip., q. s., ad f^iij. 

M. 

S. — One teaspoonful p. r. n. 

The temperature must be maintained by hot flannel wraps and 



264 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

hot water bottles, and the child kept in a horizontal position and 
disturbed as little as may be. 

In this stage astringents are still indicated ; but opium must 
be used with great caution, or even discontinued entirely, when 
there are cerebral symptoms and semi-coma. 

In the fortunate instances in which this plan is successful, it 
is still necessary to treat the succeeding diarrhoea, and finally, 
to build up the general health by good food, tonics and fresh 
air. 



10. INFLAMMATION OF THE COLON AND 
RECTUM— DYSENTERY. 

Dysentery is not a very frequent disease in children, but it may 
occur in an endemic or epidemic form, and as a sequel of measles, 
scarlet fever, or variola. 

Morbid Anatomy. — The mucous membrane of the colon and 
rectum is swollen, red, softened and even loosened by diffuse 
suppuration, and the solitary glands are enlarged and ulcerated, 
while the corresponding peritoneal surface is congested. In 
severe and epidemic cases, the inflamed surface presents more or 
less adherent pseudo-membranous patches, which, when removed, 
leave ulcers of irregular outline and variable depth. Perforation 
and cicatricial contraction of the intestine are occasional results. 

Etiology. — Sporadic and endemic cases are produced by the 
same causes as entero-colitis — excessive heat, bad food, and ex- 
posure to cold and wet. The epidemic form is certainly infec- 
tious, and there are grounds for believing that it is also contagious, 
although the last fact is not yet definitely established. The 
disease is most common in the second and third years of life, and 
seems to attack boys more frequently than girls. 

Symptoms. — Nausea, vomiting, high fever, and acute abdominal 
pain usher in the attack. Then the bowels become distended. 
The evacuations are numerous, ranging from four to forty a day ; 
small in quantity and voided with much straining. At first they 



AFFECTIONS OF THE STOMACH AND INTESTINES. 265 

contain faecal matter, but after a short time are composed entirely 
of mucus and blood, mixed with yellow or green flocculi, frag- 
ments of false membrane and pus. The blood may appear in 
dark red streaks or clots ; in black masses ; as a substance 
resembling the washings of meat, or merely diffused through the 
mucus, giving it a uniform red color. Their odor is most offen- 
sive. 

The face wears an anxious expression ; there is great restless- 
ness, sleeplessness, muscular weakness, and rapid emaciation. 
The tongue is dry, red at the tip and edges, and covered in the 
centre with a brownish coating. There is anorexia and urgent 
thirst. The abdomen is distended, tympanitic, and painful on 
pressure, particularly over the course of the colon. 

As the attack progresses, tenesmus becomes the most perma- 
nent symptom ; it occurs without the passage of stools, and is 
often attended with prolapse of the rectum. Fever gives place 
to coolness of the surface; restlessness, to semi-stupor; the eyes 
and cheeks sink ; the face becomes pinched, and death may take 
place quietly or be preceded by slight convulsions. 

The duration varies from two or three days in grave cases, to 
about two weeks in those that result favorably. 

The Diagnostic features are high fever, tenderness along the 
track of the large intestine, tenesmus and the number and char- 
acter of the stools. 

The Prognosis is favorable in the sporadic form and when 
there is only slight elevation of temperature and moderately fre- 
quent stools. Quite the reverse, if there be high fever, great 
tenesmus, frequent evacuations containing much blood or false 
membrane and pus ; when there is a tendency to collapse, and 
when the disease is epidemic. Relapses frequently occur. 

Treatment. — Children affected with dysentery must be kept 
at rest in the best room — so far as ventilation and coolness are 
concerned — that the house affords. Their diet should be liquid, 
and even this form of food must, on account of the irritability 
of the stomach, be given in moderate quantities. From four to 



266 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

six ounces of whey and cream mixture ; of flour-ball and milk, 
or arrow-root and milk, may be given every three hours to a child 
of two years. A good preparation is : — 

Arrow-root, gj. 

Hot water, f ^ ss. 

Mix thoroughly, and add to — 

Milk, fgij. 

Cream, f^ss. 

Water, f^j. 

Small pieces of ice and moderate quantities of iced filtered 
water can be allowed to relieve thirst. 

Two or three times daily the body should be thoroughly 
sponged with water at a temperature of 95 ° F., and the abdomen 
must be kept covered with a light flaxseed poultice, over the 
surface of which a little mustard has been sprinkled ; this must 
be covered with oiled silk and changed as often as it becomes 
cold. 

If the patient be seen early in the attack, the medicinal treat- 
ment may be begun with a laxative, as : — 

B . Ol. Ricini, f 3 ijss. 

Pulv. Acacige, ^ij. 

Tr. Opii, TT\viij. 

Aq. Menth. Pip., q. s. ad f^ij. 

M. 
S. — One teaspoonful every three hours, at three years of age. 

After this has been continued for twenty-four hours, there 
should be marked improvement in the evacuations. If this be 
not the case, it is well to order the following : — 

R. Pulv. Ipecac. Comp., gr. vj. 

Bismuthi Sub-carb., £j. 

Pulv. Aromat, gr. vj. 

M. et ft. chart. No. xij. 
S. — One powder every three hours. 

With an enema of laudanum — gtt. iij to fgss of warm water — 



AFFECTIONS OF THE STOMACH AND INTESTINES. 267 

every four hours; or a suppository of opium and acetate of 
lead : — 

R . Pulv. Opii, gr. ss. 

Plumbi Acetat., gr.}. 

Ol. Theobromae, 3J. 

M. et ft. supposit., No. vj. 
S. — One to be used every four or six hours. 

Should these fail, nitrate of silver may be administered by the 
mouth or rectum. If there be great rectal irritability and quick 
expulsion of the caustic injections, it is best to follow them with 
enemas of laudanum. A good formula for administration by the 
mouth is : — 

R. Argenti Nitrat., g r -j- 

Tr. Opii Deod., TT\,xxiv. 

Syr. Acaciae, f.^j. 

Aquae, q. s. ad fgiij. 

M. 
S. — One teaspoon ful every three hours. 

For an enema : — 

R. Argenti Nitrat., . gr.j. 

Aquae Dest, ^'j- 

M. 
S. — Inject twice daily, and allow an interval of twenty-four 
hours after three days' successive use. 

To ward off prostration, it is necessary to employ stimulants, 
in doses and at intervals proportionate to the demands of the 
case. Should collapse occur, alcohol and artificial heat to main- 
tain the body temperature are the main resources. 

When convalescence is established, it is still necessary to guard 
the diet carefully and to build up the general health with tonics. 
Of these, the best are quinine with dilute nitro-muriatic acid, 
or tincture of nux vomica with compound tincture of gentian, 
followed by ferrated elixir of cinchona, or citrate of iron and 
quinia. 



268 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ii. TUBERCULAR ULCERATION OF THE IN- 
TESTINES. 

This form of ulceration commonly occurs as a complication of 
pulmonary and abdominal tuberculosis. Gray granulations may 
or may not be present at the site of lesion, but the special degen- 
erative process in the intestinal mucous membrane is so intimately 
associated with tubercle that the term " tubercular ulceration/ ' 
seems to be warranted. 

Morbid Anatomy. — The lesions are chiefly confined to the 
ileum, and primarily affect the solitary follicles and Peyer's 
patches, particularly those about the ileo-caecal valve. The 
follicles become enlarged from multiplication of their cell ele- 
ments, then undergo caseous degeneration and softening, with 
the formation of isolated ulcers in the case of the solitary glands, 
and clusters of coalescing ulcers in that of the patches of Peyer. 
From having, at first, the shape of the follicles and patches, they 
gradually extend by a similar process of corpuscular infiltration, 
caseation and softening in the surrounding tissues. The fully- 
formed ulcers are irregularly oval in shape, with their greatest 
diameter directed transversely to the axis of the gut ; their edges 
are indented, thick and somewhat undermined ; their floors are 
red or gray, and formed by one or the other tissue of the intes- 
tine, as far down as the peritoneum, according to the depth of 
destruction. Perforation is rare on account of localized adhesive 
peritonitis. Gray granulations — a secondary product — may be 
found in the tunica adventitia of the small arteries and lymph- 
atics, or on the reddened and cloudy peritoneal surface corres- 
ponding to the ulcers. Cicatrization takes place rarely, but may 
be the cause of stricture. 

The uninvolved mucous membrane is congested, thickened 
and softened. The mesenteric glands are enlarged and cheesy, 
and miliary tubercles are usually found in the lungs or else- 
where. 

Etiology. — The disease is met with in children who have 
passed the fourth year, and in whom the tubercular or strumous 



AFFECTIONS OF THE STOMACH AND INTESTINES. 269 

diathesis exists. Bad hygiene, bad food, and exposure, act as 
predisposing causes, by interfering with general nutrition and 
paving the way for the development of the diathetic tendency. 
An unsuitable diet, too, may indirectly lead to this form of ulcer- 
ation, by bringing about an abnormal condition of the lining 
membrane of the bowel. 

Symptoms. — In addition to the features indicating a scrofulous 
or tubercular tendency, the child, after suffering for a variable 
time from the symptoms of simple intestinal catarrh, begins to 
have fever and to pass excessively offensive stools, composed of 
dirty-brown liquid that, on standing, deposits flocculi, mucus, 
pus and small, black clots of blood. There is colic preceding 
the evacuations ; moderate distention of the belly, with tension 
of the parietes over the right iliac region, and tenderness on 
pressure there. Abdominal palpation also reveals enlargement of 
the mesenteric glands, and physical examination of the chest the 
evidences of pulmonary phthisis. Such cases usually result 
fatally, after a more or less protracted course, the direct causes 
of death being tuberculosis of the lungs or of the meninges of 
the brain. 

Treatment. — Pure air, warm clothing, good food and tonics 
comprise the measures of treatment. The best of the tonics is 
cod-liver oil, which, in these cases, often seems to lessen the 
tendency to diarrhoea. Half a teaspoonful three times daily is 
quite enough for a child of five years. It may be given com- 
bined with maltine, or in an emulsion with lacto-phosphate of 
lime, or the compound syrup of the hypophosphites. The follow- 
ing is an admirable formula : — 

R. Olei Morrhuas, . . fgij. 

Ext. Malt (dry), giv. 

Calcii Hypophos., 

Sodii Hypophos., aa gr. xvj. 

Potassii Hypophos., gr. viij. 

Glycerinae, f ^ ij. 

Pulv. Acaciae, £ij. 

Aquae, q. s. ad fj§ iv. 

M. 

S. — One teaspoonful three times daily. 



270 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

In addition to this general treatment, attention must be paid 
to the intestinal condition. A light flax-seed poultice should be 
placed over the right iliac region or over the whole abdomen, 
or a dressing of cotton, covered with oiled-silk, may be used. 
Internally, sub-nitrate of bismuth with compound ipecacuanha 
powder and nitrate of silver are useful ; at the same time it is 
well to administer clysters of laudanum. 



12. COLIC. 

Colicky pains frequently attend dysentery, constipation and 
other intestinal disorders ; but colic with flatulence so uniformly 
occurs as a functional affection in children from birth to the end 
of the third month, and gives so much discomfort both to the 
infant and its attendants, by causing fretfulness, crying and wake- 
fulness, that it demands separate consideration. 

Etiology. — In studying the causation of this condition, it 
must be remembered that after birth the infant, previously nour- 
ished through the blood of its mother, begins to take food 
through a new channel. Hence a new habit has to be formed, 
in addition to the development of a secreting and absorbing 
apparatus hitherto inactive. It is during this transition state that 
food of the best quality may be imperfectly or slowly digested 
and flatulence and colic result. 

Food that is at all difficult to digest almost always occasions 
colic, and hand-fed babies are especially liable to it. Other 
causes are fulness of the stomach in over-feeding, or the opposite 
condition of emptiness after nursing at a breast that affords milk 
in small quantity, and, finally, inherited feebleness of digestive 
power, and over-sensitiveness of the mucous membrane to the 
contact of food. 

Symptoms. — Soon after feeding, the infant becomes restless, 
kicks his legs about uneasily, twists his body, grunts, or utters a 
series of piercing cries. The face is congested at first, from the 
effort of crying, but soon becomes pale, with a tinge of blue 



AFFECTIONS OF THE STOMACH AND INTESTINES. 271 

around the lips. The belly is full and hard, the hands and feet 
are cold, and, in bad cases, the fontanelle is more or less de- 
pressed. After a time, varying from a few minutes to an hour, 
eructations of flatus or of curdled milk occur, and the symptoms 
disappear for awhile. Such paroxysms may occur at any hour of 
the day, but are most frequent and severe in the evening and 
night. 

There is usually, also, a moderate degree of constipation, or 
the bowels are irregular. At night the rest is broken by uneasy 
tossing and whimpering, and during sleep a smile or an expres- 
sion of pain often flits over the face ; but, in spite of the fretful- 
ness and discomfort, the infant suffers little in general health, 
and increases in flesh and strength almost as rapidly as is normal. 

Treatment. — When the infant is fed at a healthy breast, it is 
of great importance to insist upon the rule of- feeding only at 
proper intervals, and absolutely to forbid the habit of putting the 
child to the breast whenever it cries. Food will be taken when- 
ever it is offered, and the warm milk entering the stomach relieves 
the pain for a time, only, however, to increase it later by giving 
the viscus more work to do, and filling it with material to under- 
go fermentation with the production of flatus. Consequently, 
it is much better to resort to one of the preparations to be here- 
after given for the relief of the pain. 

Should the child draw but a poor and scanty supply of milk, 
and the colic be due to emptiness, the breast must be supple- 
mented by hand-feeding. Under these circumstances, and when 
the whole feeding is by bottle, much may be done to prevent or 
relieve the attacks of pain by attention to cleanliness of the feed- 
ing apparatus; by carefully selecting the ingredients of the food, 
and by adding an aromatic to the latter. A good food for a 
child of one month old is : — 

Milk, . . . f^jss. 

Cream, f^ij- 

Barley-water, ^3J SS * 

Caraway-water, f^j. 

Sugar of milk, 3 ss. 



272 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

These ingredients are to be mixed in a clean vessel, poured 
into a perfectly clean bottle, and heated to a temperature of about 
98 F. in a water-bath.* 

A little pancreatin and bicarbonate of sodium added to the 
bottle of food just at the time of its administration produce good 
results by aiding intestinal digestion. 

When the bowels are inclined to constipation, the barley-water 
may be replaced by a gruel made of ground oatmeal (Bethlehem 
brand). One or two teaspoonfuls of the meal to the quantity of 
water necessary for each bottle is the proper proportion. In 
place of this, a teaspoonful of Mellin's food may be added to 
the requisite quantity of water. 

The belly should be anointed twice a day with warm olive oil, 
and enveloped in a broad flannel binder. It is even more im- 
portant to keep the feet warm, and for this purpose thick socks 
or long woolen stockings should be worn, and in bad cases, arti- 
ficial heat must be applied by hot water bottles. 

Medicines are indicated chiefly during the attacks of pain. A 
simple and serviceable prescription is ten drops of gin in a tea- 
spoonful of sweetened warm water. Another is : — 

R. Sodii Bicarb., . . . gr. xvj. 

Syrupi, f^ss. 

Aq. Menth. Pip., q.s. ad fgij. 

M. 

S. — One teaspoonful p. r. n. for a child of one month. 

This is rendered more efficient by the addition of two drops 
of aromatic spirit of ammonia to each dose, or, in severe cases, 
one drop of spirit of chloroform. 

Bromide of potassium and chloral are most useful ; they may 
be combined as follows : — 

R . Potassii Bromidi, gr. xvj. 

Chloral Hydrate, gr. viij. 

Syrupi, f^ss. 

Aq. Menthse Pip., q. s. ad f ^ij. 

M. 
S. — One teaspoonful for a dose. 

* A tin-cup half filled with water, placed on an ordinary stand over a gas- 
burner, makes a good water-bath for nursery use. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 273 

Of this preparation, it is rarely necessary to give more than 
two or three doses, at intervals of half an hour. It is well to 
reserve this mixture for severe attacks, and in ordinary cases, to 
use the gin or the soda mixture. 

Should the paroxysm be so violent as to lead to depression of 
the fontanelle and threaten collapse, the infant must be placed in 
a warm bath for five minutes ; after being removed and carefully 
dried, he must be wrapped in a blanket ; a flax-seed poultice with 
a dash of mustard placed over the abdomen ; a hot- water bottle 
applied to the feet ; the bowels relieved by an enema of warm 
water, and ten drops of gin or brandy in warm water adminis- 
tered by the mouth. If the fontanelle still remains depressed, 
the stimulant must be continued in doses and at intervals propor- 
tioned to the urgency of the symptoms ; at the same time the 
soda and ammonia mixture may be given. 

As a routine treatment to improve digestion, it is well to order 
fifteen drops of essence of pepsin (Fairchild's) three times daily. 



13. HABITUAL CONSTIPATION. 

In addition to the locking of the bowels that results from 
mechanical causes, as intussusception, peritoneal adhesions, and 
so on, or from paralysis of the muscular coat of the intestine in 
certain nervous diseases, constipation of a functional character is 
a frequent and often an obstinate condition during childhood. 

Etiology. — Before the completion of the first dentition, it is 
more common in hand-fed babies than those nursed at the breast, 
and is due to the use of milk over-rich in casein ; the abuse of 
starchy food ; an insufficient supply of water, and often to the 
action of popular remedies given to relieve colic. With children 
who have passed the first dentition, constipation arises from faulty 
habits, and from the employment of a diet that is either bad in 
quality or unsuitable from its too great sameness. In all cases, 
inherited sluggishness of the peristaltic movements must be re- 
membered as a possible cause. 

2 3 



274 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Symptoms. — These vary greatly in degree. Thus, an infant, 
instead of the normal number, may have but one evacuation a 
day, or one, two, and even three days may intervene between 
the movements. The stools are scanty; composed of hard, dry, 
whitish lumps, and are voided with much pain and straining. 
Should the last symptom be severe, it is frequently attended by 
rectal prolapse and hemorrhage. Other features are colic, 
abdominal distention, diminished appetite, occasional vomiting, 
feverishness, fretfulness, restless sleep, and, in bad cases, convul- 
sions. 

In older children there may be one scanty passage each day, 
or a week at a time may elapse without relief. The stools, while 
lumpy and hard, are dark colored and mixed with mucus. The 
abdomen is the seat of pain, and may or may not be distended 
with flatus ; in the latter event, palpation often reveals the pres- 
ence of hard masses along the course of the descending colon. 
The tongue is coated ; the appetite capricious ; there is nausea 
and a sensation of discomfort in the rectum, leading to frequent, 
though unproductive, straining efforts at defecation. There is 
also languor, irritability of temper, headache and restless sleep; 
a muddy complexion and general spareness of frame. 

Diagnosis. — There is little difficulty in establishing the exist- 
ence of habitual constipation. One must be cautious, however, 
not to place too much reliance upon the statement that " the 
child's bowels are open every day," for in obstinate cases, it is 
not unusual for daily evacuations of thin, worm-like masses to 
take place whilst the bulky and hard faeces are retained. 

Prognosis. — Proper management rarely fails in regulating the 
action of the bowels, but constipation may prove serious in two 
ways : first, by leading to faecal accumulation ; second, by gene- 
rating a condition of general ill-health, during which the child 
is more exposed to the attack of acute and dangerous disease. 

Treatment. — In every case the relief of the actual state of 
retention of faeces in the rectum and the breaking up of the 
costive habit are the ends to be accomplished. 

For the former purpose, I prefer the use of purgative enemata 



AFFECTIONS OF THE STOMACH AND INTESTINES. 275 

and suppositories to the administration of the same class of reme- 
dies by the mouth, particularly when abdominal palpation or 
digital examination of the rectum show that the retained mass is 
large and hard. The author's plan is to inject into the rectum, 
according to the age of the patient, from one to four teaspoonfuls 
of warm sweet oil ; allow it to remain for six hours, and then 
use one or more clysters of soap and warm water, or olive oil, 
soap and warm water.* The preliminary injections of oil soften 
the faeces, while the clysters — which must vary in bulk from one 
to six fluidounces, to be adapted to the capacity of the gut — have 
the additional effect of distending the walls of the rectum, and 
thus bring about muscular contraction and expulsion of its con- 
tents. Should the mass present at the anus but be too bulky to 
escape, more liquid may be injected, and if this fail, it must be 
broken up by the finger and its passage assisted by gently support- 
ing the perineum during the straining efforts. In severe cases 
little result may follow a single application of this method, 
though a course of one or two oil injections and purgative clysters 
daily for several successive days will rarely fail to empty the 
bowel. 

When the soapy water and oil fail to produce expulsive efforts, 
the enemata may be rendered more efficient by the addition of 
a teaspoonful or more of castor oil or oil of turpentine. To 
make such an enema for a child of two years : — 

Take— One teaspoonful of oil of turpentine, 
Two teaspoonfuls of olive oil, 
The yolk of one egg. 
Mix thoroughly, and add, with constant stirring, to 
Four fluidounces of warm water. 

Another enema which rarely fails to act quickly and efficiently 
is from one to two fluidrachms of pure glycerine with half a 
fluidounce of water. 



*An enema composed of one teaspoonful of common salt to four fluid- 
ounces of warm water is very efficient. 



276 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

All injections must be thrown in gently, and the action of the 
syringe stopped as soon as pain is produced. 

In infants, unless the rectum be very full, clysters give no 
better results, and are far less convenient than suppositories. 
At the age of two months the following prescription may be 
ordered : — 

R. Saponis, gr. vj. 

Olei Theobromse ^j. 

M. et. ft. supposit. No. vj. 
S. — One to be inserted every morning or morning and evening. 

Or a small glycerine suppository may be used. 

Careful regulation of the diet is often all that is required to 
remove the tendency to constipation, and is a most important 
element of the treatment even in those cases where it is necessary 1 
to call in the aid of medicines. 

Bottle-fed babies must be fed upon cows' milk, so modified 
by the addition of cream, sugar of milk and water as to be as 
nearly like human milk as possible ; and, should the bowels still 
remain confined, some laxative article, as Mellin's food or oat- 
meal, can be added. An admirable mixture for a child of three 
months is : — 

Milk, f'g'&s. 

Cream, f§ ss ' 

Sugar of milk, gj. 

Bethlehem oat-meal (fine powder), ^ij. 

Water, . . fgiss. 

In preparing this, the water must be heated — just short of boil- 
ing — in a tin vessel, and the oat-meal added slowly, with stirring, 
until a smooth, white mixture is obtained ; the other ingredients 
are then to be added, and the whole administered from a perfectly 
clean feeding-bottle. It is usually unnecessary to add the oat- 
meal to every bottle ; one or two meals of it, each day, being 
sufficient. 

During childhood the food selected must be of good quality, 
thoroughly digestible and varied. Starches and meat are to be 
allowed in moderation ; pastry, salt meat and sweets forbidden, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 277 

and a judicious use made of such articles as oat-meal or cracked 
wheat in the form of mush, well-cooked spinach, celery, cabbage 
and peas, baked apples, stewed prunes, thoroughly ripe peaches 
and pears, or the juice of oranges. 

To encourage peristalsis, warm sweet oil may be gently rubbed 
into the skin of the infant's abdomen twice daily, the natural 
course of the colon being followed ; and with children more 
advanced in age, cold spongings of the belly, followed by fric- 
tions with a coarse towel until the surface is red, are very bene- 
ficial. 

The ordinary cathartics, castor oil and rhubarb, are not 
adapted to the treatment of habitual constipation, because their 
primary laxative action is followed by a secondary binding effect, 
and they consequently increase the original trouble. There are, 
however, other medicines of the same class that are free from this 
disadvantage, and one of them, or, better, a combination of 
several of them, may be employed. 

For infants a very serviceable prescription is : — 

R . Mannse Opt., ...... 

Magnesii Carb., aa £ij. 

Ext. SennseFld., ; . . . . . . . fgss. 

Syrupi, fgj. 

Aq. Menth. Pip., . . q. s. ad fgiij. 

M. 
S. — A teaspoonful once, twice or three times daily for a 

child of six months. 

Or should a sallow skin, yellowish conjunctivae and loaded 
tongue indicate torpor of the liver : — 

R . Resinse Podophylli, ............ gr. ss. 

Alcohol, n\xlviij. 

Syrupi, . ...... ..... . . q. s. adfgiij. 

M. 
S. — A teaspoonful two or three times daily for a child of one 
year. ....,.■ 

If it be difficult to make the infant take medicine, manna — 
which imparts only a sweet taste — may be dissolved in the food, 



278 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

and given from the bottle as often as required. Phosphate of 
sodium — an admirable laxative — can also be administered in the 
same way, in doses of two to five grains three times each day, at 
the age of six months. 

Children of three or four years and upward do best upon aloes 
and belladonna. Tincture of aloes and myrrh in doses of five 
drops thrice daily, or in a single dose of ten drops at bedtime, 
acts well ; but if the patient be old enough to swallow a pill, the 
following prescription is to be preferred : — 

R . Ext. Belladonnae, gr. ss. 

Pil. Aloes et Myrrh., gr. vj. 

01. Cari, gtt. iij. 

Ext. Taraxaci, gr. xij. 

M. et ft. pil. No. xij. 
S. — One pill at bedtime for a child of six years. 

Or the aloes and belladonna may be combined in a mixture,* 
thus: — 

R. Tr. Belladonna?, . f^j. 

Tr. Aloes et Myrrh., f ^ ss. 

Mucilag. Acaciae, q. s. 

Aquae Menth. Pip., q. s. ad f^ iij. 

M. 
S. — One teaspoonful for a dose. 

In using aloes and myrrh, it is usually necessary to reduce the 
dose after a time, as its purgative action increases rather than 
diminishes with repetition. 

* A clearer mixture may be made by using a solution of aloes and myrrh in- 
stead of the officinal tincture. The following is the formula : — 

R . Aloes, 

Myrrh, aa gr. ijss. 

Alcohol, fgss. 

Glycerinae, fjf j. 

Aquae, q. s. ad f ^ iij. 

M. 
This solution was compounded, at the author's request, by Mr. J. J. Ottinger 
of Philadelphia. The dose is the same as the tincture. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 279 

Another useful laxative is cascara, in the form of a fluid extract 
or an elixir ; of the first preparation ten drops, of the second, 
twenty drops may be given, once or several times daily to a 
child of six. It does not quickly lose its effects by repetition. 

I have lately used with much satisfaction a laxative confection, 
composed of tamarind pulp (gr. xxxvj) and senna in powder 
(gr. iv), aromatized with aniseed and lemon, and acidulated 
with tartaric acid. One of these may be eaten every evening, 
or as often as necessary, by a child of three years of age. They 
are regarded as sweets rather than medicine, and the little 
patients eat them readily. Glycerine suppositories may also be 
used once or even twice a day if occasion require. 



14. SIMPLE ATROPHY. 

Simple atrophy, or, as it is often termed, marasmus, is a con- 
dition in which there is extreme wasting of the soft tissues of the 
body, either without special organic lesions or with catarrhal in- 
flammation of the mucous membrane of the gastro-intestinal 
canal. 

Morbid Anatomy. — After death, the muscular and other 
tissues are found in a state of atrophy, and there is a total dis- 
appearance of normal fat from the body. Fatty degeneration 
of the kidneys, lungs and brain may be discovered ; the stomach 
is sometimes ulcerated, and hemorrhagic effusions into the cra- 
nium are not uncommon. 

Etiology. — Wasting usually occurs during the first twelve 
months of life, though it may begin in the second year, and is 
most frequently encountered among children of the poor. It 
arises both in breast-fed babies and in those brought up by 
hand, being, in either case, due to insufficient nourishment. 

Food can be insufficient in two ways : first, when it is supplied 
in amounts too limited to meet the demands of the system ; and 
second, when it contains a minimum of the elements essential to 
nutrition, or presents them in a form ill adapted to the feeble 



280 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

digestive powers of infancy. For example, nursing infants waste 
in consequence of feeding either from a breast that yields too 
little good milk, or from one that secretes abundantly a poor, 
watery fluid entirely unfit for nourishment. With artificially 
fed children, on the other hand, it rarely happens that the quan- 
tity of food is too small ; the fault lies, rather, in the direction 
of quality. Undiluted cows' milk ; milk thickened with starchy 
materials ; farinaceous foods, and even table food — meat, vege- 
tables, and bread — are given to babies a few weeks or months 
old. Now, all of these are highly nutritious, but the digestive 
apparatus is not sufficiently developed to prepare them for ab- 
sorption. They are strong foods, adapted to nourish and 
strengthen much older children and adults, but as the infant 
cannot appropriate them, he starves as surely, if more slowly, 
than when taking no food at all. Such aliment, also, while 
remaining undigested in the stomach and intestines, undergoes 
fermentation with the formation of irritant products, causing 
vomiting or diarrhoea; conditions that still further lower the 
vital powers and hasten atrophy. 

It is often possible to trace the disease directly to want of 
cleanliness in the feeding apparatus, and especially to the use of 
a form of bottle that has lately been very popular. This bottle 
has, in place of a plain gum tip, an arrangement of glass and 
rubber tubing of small calibre. One extremity of the rubber 
tubing, which is eight or nine inches long, terminates in a small 
nipple-shaped tip and bone shield ; the other, after penetrating 
an ornamental rubber cork, is fitted to a bit of glass tubing long 
enough to extend quite to the bottom of the bottle. By this 
plan, the trouble of holding the bottle and keeping it at a proper 
angle during feeding is avoided. The seeming advantage, 
though, is counterbalanced both by the minor drawback that the 
child, left to itself, is apt to continue suction long after the 
bottle is exhausted, thus swallowing a quantity of air, and by the 
greater disadvantage that the tubing can never be kept clean. 

For a number of years the author has made it a rule to ask for 
the bottle of every hand-fed infant presented for treatment, and 



AFFECTIONS OF THE STOMACH AND INTESTINES. 28 1 

few days have passed without his seeing several of the compli- 
cated contrivances referred to. In almost every instance, not- 
withstanding the most careful and frequent cleansing, a sour odor 
could be detected, and if milk were present, it contained numer- 
ous small curds ; while in cases of carelessness the odor was in- 
tolerable, and the interior of the tubing was encrusted with a 
layer of altered curd. With ordinary bottles, on the contrary, 
alterations in the character of the milk and coating of the 
interior of the tips were very infrequent. As there is little diffi- 
culty in keeping the bottles themselves clean, there can be only 
one reason for this difference, namely, in the old-fashioned in- 
strument the nipple is readily removed and as easily inverted 
and cleaned, but in the other there is no way of cleaning thor- 
oughly the twelve or more inches of fine tubing. The latter 
cannot be inverted, and the passage of a stream of water, or of a 
small, stiff brush, only imperfectly removes the milk clinging to 
the interior. This, of course, soon undergoes decomposition, 
and in this state quickly inaugurates change in the next supply 
of milk placed in the bottle. It is evident that a constant sup- 
ply of food, no matter how good originally, thus rendered acid 
and partially curdled, must, like an excess of farinaceous or 
other unsuitable food, produce irritation of the alimentary canal, 
interfere with the processes of nutrition, and lead to a state in 
which the features of wasting and disordered digestion are com- 
bined. 

The custom of preparing in the morning a supply of food 
sufficient for the whole day is another fruitful cause of atrophy. 
If this be done, no matter how carefully the mixture be propor- 
tioned, or how well adapted to the age and digestion of the 
child, it becomes unfit for consumption after standing eight or 
ten hours. The change may or may not be appreciable to 
the senses, but test-paper will always show acidity and the 
microscope demonstrate the existence of actively moving 
bacteria. 

Finally, food upon which a child has thrived for three or four 
months, perhaps, can become unsuitable and, consequently, lead 
24 



282 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

to wasting, if the digestive powers be suddenly reduced by an 
intercurrent disease. 

Symptoms. — The clinical features differ materially, according 
to whether the element of insufficiency be one of quantity or 
quality. They may, therefore, be divided into two classes, viz : 
those developed by food that is suitable but not sufficient ; and 
those resulting from unsuitable food. 

The first group of symptoms is most frequently encountered 
in children who have been nursed at the breasts of feeble or 
over-worked mothers, in whom the milk is often both scanty and 
of poor quality. There is a gradual loss of plumpness ; the 
muscles grow flaccid, and there seems to be an arrest of growth. 
The face is white ; the lips pale and thin, the skin harsh and dry 
or too moist, and the anterior fontanelle level or slightly depressed. 
The temper is irritable and sleep restless and disturbed, or the 
child is abnormally quiet, dozing constantly, and sucking his 
fingers until they become raw. When nursed, the child seizes 
the nipple ravenously ; then, if there be little milk, he quickly 
drops it to cry passionately, as if disappointed at not being able 
to satisfy his hunger; but if the milk be abundant, though thin, 
he will lie a long time quietly at the breast and often fall to sleep 
with the nipple in his mouth. The bowels are inclined to con- 
stipation, the stools being scanty, hard and dry. Physical signs 
connected with the chest and abdomen are negative, and no 
indication of disease of any special organ of the body can be 
detected. 

In the second class, features of wasting are associated with 
those of irritation of the alimentary canal, and the symptoms 
altogether are much more grave than in cases of the preceding 
group. The subjects are almost invariably hand-fed infants. 

Emaciation progresses with a rapidity and to an extent de- 
pending upon the original strength of the child's constitution ; 
the age at which artificial feeding is begun, and the sort of food 
employed. It is often so extreme that an infant several months 
old weighs less and appears smaller than at birth, and this, even 
after a large quantity of food, such as it is, has been consumed. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 283 

The combination of great wasting with a voracious appetite, is * 
very striking, and is only apparently contradictory, since hunger 
— the demand .of the tissues for reparative material — cannot be 
appeased by food which, from its bad quality, is incapable of 
digestion or proper preparation for absorption and assimilation. 
Unsuitable food, too, by irritating the mucous membrane of the 
stomach, creates a fictitious appetite. 

Sooner or later the face becomes pinched, the eyes are sunken, 
the lips pale, and when moved display a deep furrow about the 
angles of the mouth ; the facial expression is uneasy or languid, 
and the anterior fontanelle is deeply depressed. The skin, gen- 
erally, is dry, harsh and yellowish ; hangs in loose folds over the 
bones, and may be mottled by an eruption of strophulus or urti- 
caria, or present red patches of intertrigo in the neighborhood 
of the genitalia and over the buttocks and inner surface of the 
thighs. The extremities are cold and the hands claw-like- 
The tongue is heavily furred or red and dry. With the mucous 
membrane of the mouth, it may be the seat of aphthous ulcera- 
tion or thrush deposit. As already stated, the appetite is often 
ravenous, and the cries of hunger are violent, oft repeated ; and 
only temporarily silenced by food ; thirst is increased ; colic is 
common ; the bowels are constipated, and the stools, which are 
voided with difficulty and straining, are composed of a few light- 
colored, cheesy lumps, partly covered with greenish mucus. 

Attacks of acute vomiting and diarrhoea often interrupt the 
regular course of the disease. At such times there is moderate 
fever during the night, though, ordinarily, the temperature is 
subnormal. Again, chronic vomiting and chronic diarrhoea* are 
apt to arise as complications, and greatly increase the danger of 
a fatal termination. 

Sleep is restless and disturbed, and many hours, particularly 
during the night, are spent in fretful crying. A common group 
of symptoms connected with the nervous system is " inward 
spasms. ' ' When these occur, the upper lip becomes livid, some- 

* See chapters on Chronic Vomiting and Diarrhoea. 



284 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

what everted, and tremulous ; the eye-balls rotate or there is a 
slight squint, and the fingers and toes are strongly flexed. They 
frequently usher in true convulsions. 

Sometimes the nervous manifestations are much more complex. 
Thus, I have seen cases where there was retraction of the head ; 
boring of the head into the pillow ; an approximation to the 
" gun-hammer " decubitus ; general hyperesthesia and the tache 
cerebrale \ all suggestive of tubercular meningitis. Such symp- 
toms disappear under an appropriate diet, with proper medicinal 
treatment, and are to be referred to an intensely excitable nerv- 
ous system ; a condition depending upon insufficient nourishment, 
and differing merely in degree from that leading to " inward 
spasms.' ' 

There is, of course, extreme prostration, the cardiac action is 
weak and the respiration shallow. The urine is citron-colored 
or very dark yellow ; has a specific gravity of 1009 to 1012.5 ; a 
strong, characteristic odor, and is diminished in quantity. It is 
always cloudy or milky, only becoming clear on the approach 
of recovery. The sediment deposited on standing, contains 
variously shaped cylinders ; fatty elements with tinted nuclei ; 
mucus ; colored uric acid ; urates in a crystallized or amorphous 
condition ; pigment, etc. The reaction is sometimes highly 
acid. The proportion of urates is decidedly, that of uric acid 
notably, and of coloring matter and extractives somewhat in- 
creased. Albumen is always present in variable quantity and 
sugar may be also frequently detected.* 

Death may be preceded by convulsions or the symptoms of 
spurious hydrocephalus, or may result from prostration. 

Diagnosis. — Great emaciation may result from inherited syph- 
ilis or acute tuberculosis, but both of these conditions are attended 
by characteristic symptoms, rendering their diagnosis a matter 
of little difficulty. 

When symptoms resembling those of tubercular meningitis 
are present, it is often necessary to delay a definite opinion. In 

* " Parrot and Robin." 



AFFECTIONS OF THE STOMACH AND INTESTINES. 285 

simple atrophy, however, the open fontanelle is level or depressed ; 
the belly is never scaphoid ; the bowels, though frequently 
constipated, are never locked ; vomiting is apt to be associated 
with diarrhoea; the respiration and pulse are regular in rhythm; 
the temperature, as a rule, is sub-normal ; there is no hydren- 
cephalic cry, and the antecedent history and the course are 
different from the tubercular disease. 

Prognosis. — A vast number of cases die annually in our large 
cities, yet the results of appropriate management are often rapidly 
and surprisingly successful. Patients should never be given up 
unless there be extreme wasting and prostration, or unless the 
symptoms of spurious hydrocephalus arise; convulsions occur; 
or obstinate chronic vomiting or diarrhoea be developed. 

Treatment. — For the arrest of wasting from insufficient nour- 
ishment, the first thing to be attended to is the diet. Without 
entering at length into this subject,* it may be stated, as a uni- 
form rule, that in selecting a diet the object should be to fix 
upon one suited to the age and digestive powers of the child, 
so that he may be able to digest, and, therefore, be nourished 
by, all the food consumed. 

Generally, infants under twelve months who have to be either 
partially or entirely " brought up by hand, " do well upon sterilized 
cows' milk, with lime-water or with barley-water. The food 
should be administered from a bottle capable of holding half a 
pint, made of colorless glass, so that the least particle of dirt can 
be seen, and provided with a soft India-rubber tip. The whole 
quantity of food intended to be given in a day should never be 
prepared at once, but each portion must be made separately at 
the time of administration. Thus, a bottle of the sort described, 
absolutely clean, may be filled with a mixture of one part of 
lime-water to two or three of sound milk, or with one part of 
barley-water to two or three of milk, to either of which may be 
added from one to two tablespoonfuls of cream and a teaspoonful 
of pure sugar of milk. The bottle must next be placed in hot 

* For the details of diet and general management, see Part II. 



286 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

water until the contents become warm, when it is ready for the 
child. 

The degree of dilution of the milk and the proportion of cream 
added vary with the age and the feebleness of digestion. Lime- 
water is the preferable diluent when there is frequent vomiting 
or acid eructation. Both it and barley-water are of service in 
preventing the formation of large, compact curds. 

After digestion has been brought into good condition by such 
a diet, the food may be cautiously increased to a standard suit- 
able for a healthy child of the same age. At eight or ten months, 
from two to four fluidounces of thin mutton or chicken broth, 
free from grease, may be allowed each day in addition to the 
milk ; at twelve months, the yolk of a soft-boiled Qgg, rice and 
milk, and carefully mashed potatoes moistened with gravy ; and 
at the end of the second year, a small quantity of finely minced 
meat. 

Once daily the patient should be bathed in warm water, or, at 
least, sponged over with warm water, and every morning and 
evening a teaspoonful of warm olive oil or of cod-liver oil should 
be rubbed into the skin over the abdomen and chest. At the 
same time, the belly must be completely covered with a soft 
flannel binder, and the feet and surface generally kept warm by 
woolen clothing. In this way attacks of colic, if not entirely 
prevented, are rendered much less frequent and severe. 

If there be intertrigo, cleanliness and the free use of oxide of 
zinc ointment usually suffice to effect a cure. 

Of medicines, bicarbonate of sodium, pepsin and cod-liver oil 
are, perhaps, the most useful. Cod-liver oil should not be given 
until the digestive powers have been brought into a comparatively 
normal state by proper food, antacids and digestants. The oil 
is most easily borne when given in emulsion, and may be advan- 
tageously combined with lacto-phosphate of lime or with the 
hypophosphites. 

Such symptoms as constipation, diarrhoea and vomiting de- 
mand, of course, appropriate treatment. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 287 

15. TYPHLITIS AND PERITYPHLITIS. 

Destructive inflammation of the coats of the caecum or vermi- 
form appendix — typhlitis — and of the post-caecal areolar tissue — 
perityphlitis — are so closely associated that it is best to study them 
together. In the caecum and appendix the inflammatory process 
may stop short of ulceration ; may proceed to ulceration with 
perforation and the production of perityphlitis, or, infrequently, 
may lead to the latter by simple extension of the morbid process 
without perforation. The independent and primary origin of 
perityphlitis is possible, perhaps, but must be extremely rare. 
Neither condition is, strictly speaking, an affection of childhood ; 
nevertheless, children between four and twelve years of age are 
liable, particularly to that form in which perforation of the 
vermiform appendix occurs. 

Morbid Anatomy. — In typhlitis without ulceration, a large 
extent of the mucous lining of the caecum or appendix is the 
seat of catarrhal inflammation, while the investing peritoneum is 
opaque and injected, and may form adhesions to the neighboring 
intestinal loops. When the inflammation advances to ulceration, 
though a more limited area be affected, there is a tendency to 
involvement, with destruction, of all the coats of the bowel ; and 
during this process the peritoneal adhesions may become firmer 
and more extensive. 

The result of the perforating ulcer depends upon its position. 
Should it be situated on the anterior wall of the caecum, the in- 
testinal contents escape into the peritoneal sack, in spite of the 
adhesions — which are rarely firm enough to offer an efficient ob- 
stacle — and produce a rapidly fatal general peritonitis. When, 
on the contrary, it occupies the posterior aspect, where the wall 
of the caecum is devoid of peritoneum, the escaping faecal matter 
enters the post-caecal connective tissue, and causes inflammation, 
with suppuration, and forms a " faecal abscess." Such abscesses 
may reopen into the intestine; may extend down the sheath of 
the psoas muscle, reaching the surface below Poupart's ligament, 
or may point in the lumbar region or in any situation along the 



288 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

iliac crest. Sometimes the ulceration stops before perforation 
occurs, and the inflammation assumes a chronic form. In such 
cases, dense peri-caecal adhesions form ; the caecum is contracted 
in calibre ; has its walls thickened, and its mucous membrane 
either " almost entirely destroyed or converted into a retiform 
and trabecular fibroid tissue/ ' * 

In the appendix the ulcer may be situated at the free extrem- 
ity, or, more frequently, at some point in the lower third of the 
canal. As to extent, the loss of substance may be small or 
involve the whole circumference. A collection of pus may be 
present in the cavity of the appendix, and it is usual to find a 
foreign body or intestinal concretion near the position of perfo- 
ration. While the ulceration is going on, firm adhesions are 
occasionally formed with the caecum ; the anterior wall of the 
abdomen, or the tissues of the right iliac fossa. If the first event 
occurs, the resulting circumscribed abscess opens into the intes- 
tine ; if the second, it points in the abdominal wall ; and if the 
third, perityphlitis is set up, with the results already described. 
Usually, however, there are no adhesions or weak ones, and fatal 
general peritonitis follows the exit of the concretion and pus. 

The concretions resemble in shape and size cherry or date 
stones. They are hard \ often laminated in structure ; have a 
smooth, waxy-looking surface; are grayish or brown in color, 
and are composed of earthy phosphates combined with inspis- 
sated mucus and faecal matter. Pins, shot and splinters of bone, 
strawberry seeds, hairs and little masses of hardened mucus, may 
form the nidus of these calculi. These articles, too, illustrate 
the class of foreign bodies which cause perforation when arrested 
in the vermiform appendix. 

Sir William Jenner, quoted by Eustace Smith, attributes the 
arrest of calculi in the appendix to malposition. "This process, 
owing to its length and the attachment of its mesentery, may be 
bent at an angle (instead of being directed upward and inward) 
so that hardened particles can slip readily into it, but are pre- 
vented from returning." f 

* Meigs and Pepper. f " Diseases of Children," 2d Ed., p. 723. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 289 

Etiology. — In addition to peculiar anatomical relations and 
physiological attributes, which render the segment of intestine in 
question very prone to disease, a constipated habit is the chief 
predisposing cause. The existence of the strumous diathesis, too, 
while it has little influence in increasing the susceptibility to 
typhlitis, does augment the tendency to ulceration and perfora- 
tion after inflammation is established. 

Retention of hardened faecal matter in the caecum, the so- 
called " typhlitis stercoralis"; accumulation of the seeds of cer- 
tain fruits, as strawberries or raspberries, in one of the pouches 
of the caecum ; the passage of these, or of intestinal concretions, 
or foreign bodies — shot, pins and bone spiculae — into the appen- 
dix, and the habitual use of coarse, undigestible food, are the 
most common excitants. Cold and exposure, blows upon the 
abdomen, and violent exertion with strain of the abdominal 
muscles, are also sometimes determining causes. 

In perityphlitis the inflammation is generally produced by the 
escape of faecal matter into the peri-caecal connective tissue. The 
perforation occasionally results from the ulceration of typhoid 
fever or of intestinal tuberculosis. 

Symptoms.— Simple typhlitis begins suddenly, with pain in 
the right iliac region, and vomiting. The pain is constant and 
severe, and is increased by coughing, sneezing, vomiting and by 
efforts to stand or walk. The vomiting is attended by distressing 
retching; is often repeated, and the ejections consist, first, of 
food, and afterwards, of bile-stained fluid. The patient has an 
anxious face ; lies on his back slightly inclined to the right side, 
with the right thigh drawn up, and complains if an attempt be 
made to straighten it. Abdominal respiratory movements are 
partially suppressed ; the right iliac region is full and even 
prominent; very tender to the touch and dull on percussion. 
Palpation, when it can be practiced, reveals a resistant mass 
occupying the site of the caecum. There is fever, indicated by 
a coated tongue, extreme thirst, a frequent and somewhat wiry 
pulse, and a temperature ranging about ioi° or 102 F. The 
bowels are confined. 



290 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

When properly managed, these symptoms disappear in from 
four to twelve days ; the bowels yield and move freely with the 
expulsion of masses of hardened faeces ; the vomiting ceases ; the 
pain abates, and the tenderness and swelling slowly subside. 

Inflammation of the appendix alone is attended by the same 
symptoms. The pain, however, is more intense, and evacuation 
of the bowel is not followed by the same rapid relief. 

Perityphlitis may be ushered in by the marked symptoms just 
described. On the contrary, the causal ulceration, as it involves 
a limited area of the caecum or appendix, may be very latent. 
In the former instances the vomiting may stop, the bowels may 
be moved, and the acute pain be superseded by aching, or all 
discomfort disappear. The tenderness and swelling of the right 
iliac region, however, remain, although they are materially 
lessened; the patient looks ill \ has a distressed face, and is list- 
less. If, as is ordinarily the case, the onset be latent, complaints 
are made only of dull aching or discomfort in the caecal region. 
These sensations are subject to exacerbations of a few hours' 
duration, when the suffering becomes acute and there is vomiting 
and fever. In the intervals, the general health is somewhat 
below par; the child, while up and about, takes little interest in 
play ; is peevish ; has a poor appetite ; is, perhaps, restless, 
thirsty and feverish at night, and has irregular movements of the 
bowels — attacks of diarrhoea alternating with constipation. 

After an indefinite time, in either case, perforation occurs. The 
event is followed by little change in the symptoms at first, but 
soon there is more constant and severe pain in the arTected'region, 
which is increased by movement or pressure ; there is greater 
fulness, too ; the bowels are confined ; sleep is more restless and 
disturbed, and there is more pyrexia. The child takes to his 
bed, where he lies on his back with the right thigh drawn up. 
If assisted to stand, he rests his whole weight on the left leg, 
keeping the right bent at the hip and knee and rotated outward, 
and limps when he walks. There may be pain in the knee, and 
any rough attempt to move the leg increases the abdominal pain. 
As suppuration progresses in the peri-caecal tissue, hectic fever 



AFFECTIONS OF THE STOMACH AND INTESTINES. 29 1 

develops, with rigors or chills, followed by profuse sweating ; a 
dry, brown tongue ; diarrhoea ; sl running, feeble pulse ; prostra- 
tion and rapid loss of flesh. The abdomen becomes distended 
and very painful ; the csecal tumor increases in size, but becomes 
softer ; there is pain in the right knee and ankle, and sometimes 
oedema of the leg. Should the abscess point toward the surface, 
the skin becomes swollen ; doughy ; dark-red or purple in hue ; 
palpation yields emphysematous crepitation, and an incision gives 
vent to brownish offensive pus and fetid gas. When the abscess 
reopens into the intestine, the local pain, swelling and tenderness 
diminish, and the general symptoms improve. 

The uncommon cases in which perityphlitis occurs without pre- 
vious typhlitis, are marked by pain ; deep tenderness and mode- 
rate fulness; but there is no tumor, in the right iliac region. 
The bowels are irregular, and there is colic and moderate fever. 

Perforation of the anterior wall of the caecum gives rise to the 
symptoms of local or general peritonitis, according to the presence 
or absence of firm adhesions. Ulceration of the appendix is 
more frequently followed by symptoms of general peritonitis 
than by those of perityphlitis, and the former may be the first 
indication of lesion of this portion of the gut. 

Diagnosis. — A sudden attack of pain referred to the right side 
of the abdomen; vomiting; constipation; a pinched, anxious 
face ; fever ; a dorso-lateral decubitus ; flexion of the right thigh, 
and the presence of an intensely tender tumor in the caecal region, 
are the characteristic symptoms of typhlitis. 

Perforative ulceration may be suspected if these symptoms dis- 
appear and reappear several times, or if, after a free evacuation of 
the bowels, local pain, tenderness and swelling continue. 

Intussusception resembles typhlitis in some of its features, but 
in this condition tenderness is a late symptom ; the tumor is 
situated more to the left of the abdomen ; sometimes the lower 
end of the invagination can be felt in rectal examination, and 
there is severe tenesmus with the expulsion of blood-stained 
mucus. 



292 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

The limping gait, with the pain and tenderness in the right 
groin which are incident to perityphlitis, may suggest hip-joint 
disease, particularly if other symptoms be but poorly developed. 
The distinction, though, can be made without much difficulty. 
In perityphlitis, although the right thigh is semi-flexed, and can- 
not be extended without great pain, it is possible, if care be 
taken, to rotate the head of the bone without causing suffering, 
and to make pressure on, or. behind, the trochanter without 
giving discomfort. The patient, too, while avoiding extension, 
will often freely flex, abduct or adduct the thigh as requested. 
Again, there is no atrophy of the thigh muscles, no flattening of 
the buttock on the affected side, and no lowering of the buttock 
fold or obliteration of the fold of the groin. Finally, the history 
shows an acute course, and there are usually other symptoms 
which directly indicate that the disease is situated in the right 
iliac region. 

Prognosis. — Simple typhlitis should almost uniformly termi- 
nate in recovery. The duration of active illness is, as already 
stated, from four to twelve days, though several weeks often pass 
before the local tenderness entirely disappears, and the functions 
of the intestine are restored. 

Ulcerative destruction of the anterior wall of the caecum 
generally results in death from general peritonitis in two or three 
days. Perforation of the appendix is always rapidly fatal. 

The termination of perityphlitis resulting from perforation 
depends upon the direction taken by the pus. When the abscess 
opens upon the surface of the body the mortality is about fifty per 
cent.; death resulting from exhaustion or extension of inflamma- 
tion to the peritoneum. A reopening into the intestine is more 
favorable, and many cases get well. Under any of these circum- 
stances the course is apt to be prolonged. 

Treatment. — For prevention, it is necessary to guard against 
habitual constipation, by a properly selected diet, by regular 
exercise, and by enforcing the rule of making daily attempts to 
evacuate the bowels at a fixed hour. Nature may be assisted by 



AFFECTIONS OF THE STOMACH AND INTESTINES. 293 

a teaspoonful of compound licorice powder at bedtime, or one 
of the following pills : — 

R . Resin. Podophylli, gr. jss. 

Ext. Belladonnse, gr. j. 

Ext. Taraxaci, gr. xij. 

M. et ft. pil. No. xij. 
S. — One pill every night for a child of six years. 
Or— 

R. Ext. Belladonna, 

Ext. Nucis Vomicae, aa gr. j. 

z Ext. Colocynth. Comp., gr. vj. 

Ol. Cari, gtt. iij. 

Confec. Rosse, gr, vj. 

M. et ft. pil No. xij. 
S. — One pill every night. 

Should there be a tendency to faecal accumulation laxatives 
are not to be administered, but the mass is to be removed by 
purgative enemata. Two teaspoonfuls of table salt to a half pint 
of warm water, will be efficient for this purpose, or one of the 
enemata mentioned in treatment of constipation, (p. 275) may 
be used. 

A child attacked by typhlitis must be put to bed, and a small 
pillow placed under the right knee to support the thigh. The 
iliac region is to be covered with hot flax-seed poultices, or, if 
the child be robust and the tenderness and pain excessive, two or 
three leeches may be applied before poulticing. No food but 
milk, or milk with a little mutton or chicken broth, is allowable, 
and these are to be given in small quantities at short intervals. 
A patient six years old may take every two hours: — 

Milk, fgij. 

Barley-water, f^>ij- 

Saccharated Solution of Lime, gtt. xv. 

Saccharated solution of lime is used as an alkali instead of 
lime-water, on account of its adding no bulk to the food : it is 
prepared in this way : — 



294 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Take of— 

Slaked Lime, gj. 

Refined Sugar, in powder, gij. 

Distilled Water, f § xvj. 

Mix the lime and sugar by trituration in a mortar; transfer to a bottle 
containing the distilled water, cork and shake occasionally for a few hours. 
Finally, separate the clear solution with a siphon and keep in a stoppered 
bottle. 

When broth is used, it may take the place of the milk at three 
or four feedings during the twenty-four hours. Should the milk 
or broth not be retained, whey mixtures, peptonized milk, and 
meat juice can be tried. 

Thirst is best relieved by small quantities of cold carbonic-acid 
water and bits of ice. 

The therapeutic indication is to relieve irritation and arrest 
excessive peristaltic action of the bowels. This is best accom- 
plished by a combination of opium and belladonna, as : — 

R . Tr. Opii., tt\,xxiv. 

Tr. Belladonnae, tt\xlviij. 

Aq. Cinnamomi, q. s. ad f^iij. 

M. 

S. — One teaspoonful every two hours. 

The action of these drugs must be constantly pushed, until 
pain be relieved or the limit of systemic toleration be reached. 
The second or third dose usually checks vomiting; but should 
this be not the case, morphia must be administered hypoder- 
mically in doses of one-sixteenth of a grain at intervals of four or 
six hours, according to its influence on the pain and its narcotic 
action. As the pain subsides the bowels act spontaneously. 

There is one rule in the treatment of typhlitis that must never 
be forgotten, namely, no purge, no matter how gentle in action, 
is to be used, either by the mouth or rectum, while the acute 
symptoms are present. After they disappear, if the bowels be 
not relieved, enemata of warm water can be given safely, but no 
purge by the mouth. Furthermore, it is well to withhold the 
latter for several weeks after convalescence is established, for 



AFFECTIONS OF THE STOMACH AND INTESTINES. 295 

there may be some latent ulceration in progress that can only 
result favorably through the formation of firm peritoneal adhe- 
sions, and nothing so surely destroys them, while in the process 
of development, as a purgative. 

As soon as the bowels are moved and convalescence begins, 
the diet may be cautiously increased ', a belladonna plaster sub- 
stituted for the poultices ; tonics administered, and the patient 
allowed to sit up in bed, and after a time, as health returns, to 
be up and about. Very active exertion should be avoided for 
several months. 

Perityphlitis demands the same rest in bed, careful dieting, 
local applications, and avoidance of purgatives. As hectic fever 
appears, the food must be more nutritious ; eggs, finely minced 
meat and beef-tea may be added to the milk. Alcoholic stimu- 
lants are also required with quinine, and, when there is great 
prostration, carbonate of ammonium. 

So soon as the abscess points it must be evacuated and a free 
discharge encouraged. In the after treatment every effort should 
be made to support the strength by good food, tonics and stimu- 
lants. 

It would not be well to leave the question of treatment with- 
out some more distinct allusion to the intervention of surgery. 
Peritonitis of every form is passing more and more into the 
hands of the surgeon, and remarkable successes have of late been 
recorded in cases which might well have been deemed desperate. 
Regarded from the point of view of the physician, the subject 
stands thus : A number — it is difficult to say how many, but 
probably a large majority — of these cases, if treated judiciously, 
get perfectly well, and an operation, however successful, might 
well be called meddlesome. In others the inflammatory process 
localizes itself; then, if the symptoms indicate no progress 
toward recovery, or are in any degree urgent, an exploratory 
incision is not only justifiable, but demanded. Next come those 
other cases already described, where the peritonitis is general, 
and in which the life of the child is in the balance. Then it is 



296 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

that the experience of other cases, that have struggled through ) 
the fear that a serious undertaking, such as opening the abdomen, 
may extinguish the last hope ; the doubt that must exist whether, 
if an operation be begun, any relief can be afforded, and similar 
considerations, make confusion when we most need calm judg- 
ment. We can be wise after the event, and talk glibly of the 
advantages of early operation, but this is small help to us when 
the point aimed at is so to time our measures as to be neither 
too soon nor yet too late. No precise rules can be established ; 
these cases must remain full of anxiety, of doubt and diffi- 
culty, and the man of courage and judgment will occasionally 
save a life by a timely and carefully-conducted operation. So 
far as advice can be given, it may be said that for a dry peri- 
tonitis probably no good will come of surgery. If any evidence 
can be obtained favoring the existence of pus or of serum — for 
the serum in these cases is irritant and noxious, and often as 
urgently calls for removal as pus — here, if the right moment 
can be seized, an incision, and such steps as may be necessary 
for cleansing the peritoneum, will sometimes prove successful. 



16. INTUSSUSCEPTION. 

In intussusception or invagination one portion of the intestine 
is forced, from above downward, into another portion imme- 
diately continuous with it. 

Apart from faecal accumulation, this is practically the sole 
cause of intestinal obstruction in infancy. For, although in- 
stances are on record in which the bowel, in children, has been 
closed by peritoneal adhesions ; by a twisted vermiform appen- 
dix, and by morbid growths, these are but pathological curiosi- 
ties. 

Two forms are met with, namely : — intussusception without 
symptoms ; and intussusception with symptoms. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 297 

INTUSSUSCEPTION WITHOUT SYMPTOMS. 

This condition, which must be regarded rather as an accident 
than a disease, is frequently encountered in autopsies upon young 
children who have met death from very diverse affections. 

Such intussusceptions occur shortly before, or during, the death 
agony, and are probably produced by irregular and violent con- 
tractions of the muscular fibres of the gut. They consist simply 
of an involution of the bowel, without evidence of inflammatory 
action at the site of lesion, and can be readily reduced by trac- 
tion. Sometimes there is but one inversion, though usually 
there are several ; as many as ten or twelve distinct invagina- 
tions, at distances of a few inches from each other, having been 
found in the same subject. The length of gut displaced is rarely 
more than three or four inches. The small bowel is the uniform 
seat ; and of this division of the intestines, the lower part of the 
jejunum and the upper part of the ileum, are most frequently 
involved. 

Without a post-morten examination, it is impossible to recog- 
nize the existence of this form of intussusception, on account of 
the entire absence of symptoms. Nevertheless, its discovery 
may be anticipated when death has resulted from cerebral or 
spasmodic diseases, or from acute or chronic entero-colitis. 



INTUSSUSCEPTION WITH SYMPTOMS. 

True intussusception is, fortunately, not very frequently met 
with in children, though it is more common in early infancy 
than in later childhood, youth or adolescence. 

Morbid Anatomy. — The probable mechanism of an intus- 
susception is that a limited portion of the intestine contracts 
forcibly, and, by elongating and moving forward, enters a non- 
contracted segment immediately below, drawing in more or less 
of the latter, together with its mesentery or meso-colon. Next, 
new peristaltic movements force the invaginated bowel further 
and further along, until extension is arrested by resistance from 
25 



298 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the mesentery, or by secondary inflammatory adhesions. The 
intussusception must, therefore, be made up of three layers of 
intestine, one above the other. The outer layer is called the 
sheath, or intussuscipiens ; the middle and inner ones, the intus- 
susceptum. Of these, the external and middle have mucous 
surfaces in contact; the middle and internal, serous surfaces. 
The involuted mesentery or meso-colon lies between the two 
last-named layers, and, on account of the firm attachment at its 
roots, exerts a one-sided traction upon the intussusceptum, curv- 
ing it upon its axis and drawing the lower opening — which is 
elongated to a narrow fissure — from the centre toward the side of 
the sheath. The sheath itself is much folded or puckered, and 
on this account, with the curving of the intussusceptum, the 
apparent length of gut involved is always much less than the 
actual length. This varies from a few inches to several feet ; 
in extreme cases an intussusception beginning at the ileo-caecal 
valve, may become apparent .to the touch or sight at the anus. 
Increase in length is accomplished by peristaltic action from be- 
hind ; it takes place, always, at the expense of the external layer, 
and depends, for its degree, upon the force of peristalsis, the 
width and laxity of the mesentery or meso-colon, and the amount 
and character of the contents of the intestine behind the seat 
of involution. 

The results of an intussusception are, first, occlusion of the 
lumen of the canal with partial, or generally complete, arrest in 
the passage of the intestinal contents ; and second, obstruction of 
the blood current in the middle and inner tubes, due to the pres- 
sure upon the mesenteric vessels. 

The obstruction of the circulation leads to deep congestion of 
the tissues of the intussusceptum ; the mass becomes purple and 
swollen ; the mucous surfaces exude a bloody material, and soon 
the opposed serous surfaces are glued together by inflammatory 
adhesions. 

Should there be complete strangulation the intussusceptum 
becomes gangrenous, and, under favorable circumstances, may 
be detached en masse or in pieces, and discharged through the 



AFFECTIONS OF THE STOMACH AND INTESTINES. 299 

anus. When this occurs, provided firm adhesions have formed, 
the sheath, being united at its upper extremity to the intestine 
directly above the point of inversion, forms, with the latter, a 
continuous tube, notwithstanding the separation of the interven- 
ing portion. 

Several accidents may happen during this process. Thus, the 
inflammation in the opposed serous coats may extend beyond the 
involution, and give rise to general peritonitis. Or, ulceration 
and perforation of the sheath may be produced by the pressure 
and irritation of the free end of the intussusceptum. Again, 
when adhesions are imperfect, the contents of the intestine may 
escape into the peritoneal cavity through a rent, resulting from 
the separation of the sloughing intussusceptum ; and, finally, 
even after the gangrenous mass is expelled, the adhesions may 
give way and permit extravasation. 

Generally, in those fortunate cases in which sloughing is fol- 
lowed by recovery, no permanent injury results from the cicatri- 
zation at the point of junction of the sheath and uninvolved 
intestine. The cicatrix, though at first contracted, gradually 
stretches and a free passage-way is established. 

Sometimes intussusception is attended with so little constric- 
tion of the involuted gut that the passage for the involved intes- 
tinal contents is quite free enough to allow of the maintenance 
of life for months, the patient finally dying of exhaustion. 

In infants the invagination is almost invariably ileo-caecal. 
The end of the ileum with the ileo-caecal valve is forced into the 
caecum, and, as the intussusception increases, penetrates further 
and further into the colon, drawing along more of the ileum, 
and doubling in, first, the caecum, and then the ascending, or even 
the transverse and descending portions, of the colon. In some 
cases a few inches of the gut pass through the ileo-caecal valve 
before the caecum is inverted. Occasionally an intussusception 
involves the colon alone, and, very exceptionally, the small in- 
testine. 

Upon opening the abdomen, in an ordinary case, much of the 
colon appears to be wanting, and a tumor is found occupying 



300 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the left side or the left iliac fossa. This mass — the intussuscep- 
tion — is slate-gray in color; elongated or sausage-shaped, and 
doughy to the touch. By more or less forcible traction, the in- 
volution may be reduced, though the gut is usually softened and 
apt to be torn in the effort. If an incision be made through the 
sheath, exposing the intussusceptum, two orifices will be observed 
at the lower end of the latter, one leading through the valve, the 
other into the cavity of the appendix vermiformis. The invagi- 
nated intestine is either of a uniform deep red color, resembling 
a long, firm clot of blood, or presents the appearances common 
to gangrenous and sloughing tissues. If death has occurred 
early, there are few evidences of inflammation between the 
serous surfaces; if later, these are adherent, the adhesions ex- 
tending a few lines beyond and above the neck of the intussus- 
ceptum on to the sound intestine. The gut situated above the 
point of obstruction is usually greatly distended with accumulated 
faecal matter and flatus; whilst that below is collapsed and 
empty, or at most, contains a small quantity of mucus, stained 
with blood, pressed out from the capillaries of the strangulated 
mass. 

As the age of the child advances the more likely is the intus- 
susception to be confined to the small intestine. 

Etiology. — As already indicated, early age seems to act as a 
powerful predisposing cause. Of fifty-two cases in children, re- 
corded by J. Lewis Smith, twenty-three occurred between the 
ages of three and six months ; eight between the sixth and twelfth 
months ; and eighteen between the first and twelfth years. Of 
Leichtenstern's four hundred cases, one-fourth occurred in the 
first year, after the third month. The greater liability in infancy 
is due partly to anatomical peculiarities, and partly to the want 
of regularity and the energy of the intestinal movements. Thus, 
in infants, the large intestine holds to the abdominal space that 
it is forced to occupy the relation of about three to one, necessi- 
tating doubling of the gut upon itself. At this time of life, too, 
the meso-colon is much wider than in later years, except where 
it passes over the kidneys, in which position it is very narrow, 



AFFECTIONS OF THE STOMACH AND INTESTINES. 30I 

or even almost absent. These two conditions, combined with 
unrhythmical and violent peristalsis, cannot but favor involution. 

Many more males are affected than females. Rilliet and Bar- 
thez record twenty-five cases, all but three in boys, and the 
statistics of other authorities bear out their figures. 

The existing causes are imperfectly understood. Attacks have 
been attributed both to obstinate diarrhoea and prolonged con- 
stipation ; to the presence of intestinal worms ; to the use of 
irritating and indigestible food ; and to external violence. 

Symptoms. — These vary considerably, according to the age of 
the sufferer and the completeness of intestinal obstruction. 

In patients under one year the onset is abrupt, whether it occur 
in the midst of health, or during the course of some derangement 
of the digestive tract. The child is seized with intense pain in 
the abdomen, turns excessively pale, screams, and then cries 
violently, writhing and drawing up his legs. The contents of 
the stomach are vomited, and usually, unless the bowels have 
been evacuated just before the attack, there is a single discharge 
of somewhat liquid feculent matter. After a time the pain 
passes away, leaving the little sufferer pallid and exhausted. 
There is now a rest from pain, but not from vomiting ; all food 
or medicines taken into the stomach are returned at once, either 
by the easy process of regurgitation, or by violent retching; and 
if the viscus be empty, the ejections consist of a little bile-stained 
mucus, or even of blood. Sooner or later — the interval varying 
from a few minutes to several hours — there is another paroxysm 
of pain, accompanied by violent tenesmus, resulting in the 
evacuation of blood and mucus. 

At this time the abdomen differs little from its normal condi- 
tion. There is no fulness nor tenderness, nor any tumor ap- 
preciable to the touch ; on the contrary, gentle friction often 
relieves the colicky pains, and the child prefers to lie upon its 
belly. The hands and feet may feel cool, though, otherwise, the 
temperature of the surface is unaltered. The mind is clear, but 
the expression of face is anxious, and denotes severe illness. 
The tongue may be lightly furred, and there is increased thirst, 



3<D2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

leading to a greedy consumption of the contents of the feeding- 
bottle, or a ravenous sucking at the breast. There is also restless- 
ness, constant whining or moaning, and an inability to sleep. 
After a period of twelve or twenty-four hours, in which the parox- 
ysms of pain and tenesmus have grown more frequent and severe, 
the abdomen becomes full ; there is tenderness in the left iliac fossa, 
and if deep pressure be made in this region, during the absence 
of pain, a distinct swelling maybe detected. The tumor gradually 
becomes more defined; it is elongated or sausage-shaped; of 
doughy consistence ; and ranges in size from that of a hen's egg 
to that of a clinched fist. Later, it may change its position, 
moving toward the left side. When easily detected by external 
palpation, the tumor may be touched by a finger inserted into 
the rectum, and under these circumstances feels much like the 
cervix uteri in a vaginal examination. Occasionally the lower 
end of the involuted intestine protrudes from the anus, looking 
riot unlike a prolapsed rectum. 

While these features are developing, vomiting continues, and 
bloody mucus is expelled, with great straining, from the rectum, 
but there is no passage of either faeces or flatus. The amount of 
blood varies considerably ; in some cases there is no more than 
sufficient to stain the diapers, in others, three or four ounces are 
voided several times daily. The tongue is red and glazed, or 
covered with a dry, brown coating ; the pulse becomes frequent 
and feeble; the temperature rises to 102 or 103 F. ; the ab- 
dominal respiratory play is restricted, and the flesh wastes. The 
urine may be greatly diminished in quantity; this, however, is 
by no means a constant condition, and seems to bear no relation 
to the seat or extent of the intussusception. 

- By the third day symptoms of collapse set in. The face be- 
comes pinched ; the eyes sunken and surrounded by dark circles ; 
the skin feels cool and clammy, and the thermometer indicates a 
sub-normal temperature. The attacks of vomiting are less fre- 
quent ; the pain less intense ; the bloody evacuations lessen 
or disappear, and the child lies upon his back, in an apathetic 
condition, with half-closed eyelids, until the end comes at some 



AFFECTIONS OF THE STOMACH AND INTESTINES. 303 

time between the fourth and sixth day. Occasionally death is 
preceded by convulsions. 

If, by any means, the invagination be reduced, the vomiting 
stops, pain disappears, flatus and thin, copious, semi-liquid and 
offensive stools are voided, and the patient finds rest in sleep. 
Afterwards there is pallor, languor and weakness, though the 
appetite quickly returns and flesh and strength are soon regained. 

When older children are attacked the picture differs in some 
of its details. 

Thus, abdominal distention appears earlier and is more marked. 
The gut behind the position of obstruction being filled with faeces 
and flatus is greatly stretched, and the outline of its coils may be 
distinctly seen and felt through the tense wall of the belly. This 
is especially the case during the paroxysms of pain, when, too, 
waves of peristalsis may be seen, and loud, gurgling sounds 
heard. The tumor is large and better defined, and the dull 
percussion sound that it yields contrasts strongly with the general 
tympany. 

Vomiting is more apt to be stercoraceous. This characteristic 
symptom is absent in many cases, and very naturally so ; for, if 
Brinton's theory be adopted, namely, that faecal vomiting is due 
to a reverse axial current in the contents of the intestine, and 
not to anti-peristalsis, it is apparent that, for the development of 
this symptom at all, the obstruction must be either in the large 
intestine or in the lower part of the ileum. The date of its onset 
must depend upon the distance of the starting-point of the re- 
verse current, or the obstruction, from the stomach ; upon the 
rapidity with which the bowel above is filled by ingestion and 
secretion ; and, should the colon alone be involved, upon the 
readiness with which the resistance of the ileo-caecal valve is 
overcome. 

Evacuations of blood are much less uniformly observed. 
Whether this symptom be present or absent depends solely 
upon the degree of constriction of the invaginated bowel. When 
the constriction is just sufficient to obstruct the circulation and 
over-fill the vessels, hemorrhage is constant ; but when there is 



304 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

actual strangulation, with complete arrest of circulation, no 
blood escapes. In older children strangulation is much more 
apt to occur than in infants, partly because the invagination 
more frequently involves the ileum or jejunum — which have a 
smaller calibre than the colon — and partly from the fact that in 
them, life being more prolonged after the accident, there is 
greater opportunity for inflammatory swelling. Hence it is that 
in this class of cases there is, in many instances, absolute consti- 
pation without bloody stools, though in others, where the intussus- 
ception is ileo-caecal or colic, hemorrhage from the anus may be 
noticed as an early and permanent feature. 

The blood appears in a liquid form, mixed with mucus, or in 
small clots. It always has the venous hue, and is darker in color 
and smaller in quantity, in proportion to the distance of the 
involution from .the anus. 

The older the child the more likely is gangrene, separation and 
elimination of the invaginated gut, to take place. This result is 
usually noted during the course of the second week of illness, 
and can be attributed to the greater power of resistance and 
tenacity of life displayed by older children than by infants. It 
is a fortunate ending, but, unfortunately, rarely occurs at any 
age. After the process of separation is completed, violent strain- 
ing efforts set in, expelling the black, ill-smelling, gangrenous 
mass, either in its entirety or in patches and shreds, together 
with a large quantity of dark, offensive, feculent matter. The 
child then falls into a deep sleep, and awakes much refreshed. 
Thirst diminishes ; the appetite returns ; the paroxysms of pain 
cease; the face expresses ease and comfort, and the path to 
health is rapidly traversed. 

When death occurs it is usually due to asthenia, and may, as 
in infants, be preceded by convulsions. General peritonitis is 
very uncommon. 

In addition to the form of intussusception just described, and 
which may be termed acute, a variety having a much more pro- 
longed course, is sometimes encountered. 

Chronic Intussusception may occur at any age, and may 



AFFECTIONS OF THE STOMACH AND INTESTINES. 305 

exist for weeks, or even months, without producing severe illness. 
It originates most frequently in ileo-caecal intussusceptions, and 
depends upon the inflammatory union of the outer and middle 
layers, and the restoration of the permeability of the inner tube 
by the complete disappearance of the swelling. The patient 
wastes, has periodical attacks of colicky pain, constipation and 
vomiting, and occasionally passes a little blood. Palpation re- 
veals a tumor that alters its position, shape and density from time 
to time, and, on account of hypertrophy of the muscular coat 
above the partial obstruction, the knuckles of the intestine show 
distinctly through the emaciated abdominal wall. 

Such cases may end in recovery, by separation ; or in death, 
by perforative peritonitis ; or by steadily increasing marasmus 
with chronic diarrhoea. 

Diagnosis. — Intussusception may be strongly suspected when 
a child in good health, or previously affected with simple diar- 
rhoea, is suddenly seized with violent, paroxysmal abdominal 
pain and vomiting, quickly followed by straining efforts, result- 
ing in the evacuation of mucus and blood, and by intense pros- 
tration. The suspicion will be reduced to a certainty if, at the 
same time, it be possible to detect a sausage-shaped tumor on 
the left side of the belly, or to touch the lower end of the in- 
verted intestine upon rectal exploration. It is necessary to 
remember, however, that often, at the commencement of the 
attack, there is a single loose feculent stool, and also that, in 
older children, bloody, mucous discharges may be entirely absent. 

The diseases witr\ which intussusception is most likely to be 
confounded are simple colic, perforative peritonitis, dysentery 
and faecal accumulation within the bowel. 

In simple colic, the pain, though often severe, is never dis- 
tinctly paroxysmal. It is attended by suppression of urine, is 
relieved by the discharge of flatus per anum, and is followed by 
copious urination. During the attacks the skin may be hot, and 
the belly is usually hard and tense. There is no vomiting, tenes- 
mus or discharge of bloody mucus. The misfortune of confound- 
ing intussusception with colic can hardly be overestimated ; for a 
.26 



306 diseases of digestive organs in children. 

laxative, as castor-oil, while relieving the latter by clearing out 
the intestinal canal, cannot fail to aggravate the former by 
increasing the force of the peristaltic contractions. 

In perforative peritonitis there is pyrexia from the begin- 
ning, the abdomen is distended and tense, and pressure in the 
right iliac region — since the seat of perforation is usually the 
vermiform appendix — produces pain. On the other hand, tenes- 
mus and the evacuation of blood and mucus from the rectum 
are never observed, neither is it possible to detect a tumor by 
abdominal palpation, nor the lower end of an intussusception by 
rectal exploration. 

Dysentery presents, in the character of the dejections and the 
severe pain and tenesmus, features similar to intussusception, but 
it lacks the sudden onset, the obstinate vomiting and the ab- 
dominal tumor. The two diseases differ, too, in their course. 

A faecal accumulation, as it produces actual occlusion of the 
intestine, has many symptoms similar to invagination. Thus, 
there is vomiting, colicky pain, tenesmus, constipation and a 
tumor. The former accident, however, is preceded, for some 
time, by the passage of hard and scanty stools ; while the attend- 
ant vomiting is less obstinate ; there are no bloody evacuations ; 
and the tumor is more superficial, more fixed, and of such con- 
sistence that it can be indented by moderately firm pressure 
with the fingers. A purgative enema, also, rapidly leads to the 
expulsion of the impacted mass and relieves the symptoms. 

Prognosis. — Every case of intussusception affords an outlook 
that is grave in the extreme, though the danger to life depends 
directly upon two factors, namely : the age of the patient at- 
tacked, and the acuteness and consequent severity of the symp- 
toms. In children under one year, death almost invariably results. 
With those who are older, the constitutional resistance being 
greater, sloughing of the intussusception is more apt to take 
place and recovery follow ; but the rarity of this fortunate termi- 
nation at any time of life, has already been alluded to. 

Treatment. — In no other disease does the prospect of success 
rest so much upon an early diagnosis and appropriate management. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 307 

The indication to be met is the total arrest of all action of the 
muscular fibres of the intestine. To accomplish this end, the 
patient must be kept in a state of absolute repose ; must be made 
to take enough opium to relieve pain and check intestinal peri- 
stalsis, and must be carefully and properly fed. 

Opium may be employed alone or in combination with bella- 
donna, and may be administered by the mouth, by the rectum 
or, in children over a year old, by hypodermic injection. A com- 
bination of the two drugs and their administration by the rectum, 
is to be preferred in ordinary cases. For a child of one year the 
following suppository may be ordered : — 

R. Ext. Opii, gr. jss. 

Ext. Belladonnas, gr. ss. 

01. Theobromae, ^ij. 

M. et ft. supposit. No. xij. 

In the beginning, one of these suppositories can be intro- 
duced every two hours ; but the interval must be lessened or the 
dose increased to the point necessary to relieve pain and tenes- 
mus. 

When the mouth is selected as the channel of exhibition, the 
opium and belladonna may be prescribed in a mixture, as : — 

R. Tr. Opii Deod., fgj. 

Tr. Belladonna?, fgss. 

Aquae Anisi, q. s. ad fgiij. 

M. 
S. — One teaspoonful every two hours (or p. r. n.) for a child 
of one year of age. 

When the hypodermic method is selected, it is still best to 
combine the two drugs, thus : — 

R . Morphiae Sulphatis, gr. J. 

Atropiae Sulphatis, gr. fa. 

Aquae Dest., fgj. 

M. 
S. — Inject ten minims p. r. n., in a child of six years. 

The application of anodynes to the surface of the abdomen 



308 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

has certainly some power in relieving pain, and should, conse- 
quently, not be neglected. For this purpose a piece of soft flannel, 
large enough when doubled to cover the whole belly, should be 
dipped in hot water, wrung moderately dry, sprinkled with a tea- 
spoonful of laudanum, laid over the surface and covered with 
oiled silk. 

As to food, only so much as is absolutely required to sustain 
life should be allowed. For the first twenty-four or forty-eight 
hours, especially if there be vomiting, food may be altogether 
withheld, and a teaspoonful of barley-water or a small bit of ice 
given every fifteen minutes to allay the thirst. Later, milk and 
barley-water for infants, and milk, beef-juice or strong beef 
essence for older children, are admissible ; but always in mini- 
mum quantities and at intervals of two or three hours. Thus, for 
a child of one year, half an ounce of milk and barley-water, in 
equal parts, every two hours, will be quite enough ; while at the 
age of six years two ounces of milk, one ounce of beef-essence, 
or half an ounce of beef-juice, every three hours, will suffice. 
It is well to peptonize the food, as in this way it is prepared for 
assimilation, and little residue is left in the intestinal canal. 
Everything must be taken cold. 

When the strength begins to fail, brandy must be adminis- 
tered. The following mixture is a good food and stimulant : — 

Brandy, 4 fluidounces. 

Cinnamon Water, 4 fluidounces. 

The Yolks of two Eggs. 

White Sugar, y^ ounce. 

Rub the yolks and sugar together, then add the cinna- 
mon water and spirit. 
Dose. — A dessertspoonful to two tablespoonfuls every two 
hours, according to the age. 

Should the patient be seen before the fourth day of the attack, 
in addition to the above measures of treatment, efforts should be 
made to reduce the involution mechanically. Mechanical inter- 
ference can be successful only before inflammatory adhesions 
have formed, and is contraindicated when there is tenderness 



AFFECTIONS OF THE STOMACH AND INTESTINES. 309 

over the seat of lesion. There are three possible ways of 
accomplishing reduction, viz., by taxis, by forced injection of 
water, and by insufflation of air. To perform either of these 
successfully the patient, unless an infant under one year, must 
be previously put thoroughly under the anaesthetic influence of 
ether. 

Taxis consists in kneading and otherwise manipulating the 
abdomen with the warmed and oiled hand ; it is usually employed 
in conjunction with one of the other methods. 

If forced enemata be resorted to, the child is placed upon his 
back in bed, with the buttocks elevated, so that the trunk is in- 
clined at an angle of 45 degrees. Then, with a Davidson's or 
Fountain syringe, the physician himself must inject, carefully 
and slowly, as much tepid water as the capacity of the intestine 
will permit. While this is being done, the abdomen must be 
kneaded in such a manner as to force the water upward along 
the bowel in the direction of the invagination. At times the 
obstruction can be felt to give way ; but the best proofs of this 
fortunate occurrence are the subsidence of the more urgent symp- 
toms and the onset of sound sleep. Soon, too, there is a dis- 
charge of bloody mucus from the rectum, and then a free, offen- 
sive, semi-fluid faecal evacuation. 

Insufflation of air is suited to those cases in which the intus- 
susception having descended into the rectum, little or no water 
can be injected or retained. The apparatus for this purpose con- 
sists of a bellows, having its nozzle attached, by means of a piece 
of flexible rubber tubing, to a caoutchouc tube about a foot in 
length ; the latter is inserted into the rectum, care being taken 
to secure a perfect fit at the anus by a packing of lint. The air 
should be pumped in slowly and gently, and during its introduc- 
tion, taxis is practiced in the same manner as in the forced injec- 
tion of water. 

Should these measures fail, or should the case be seen for the 
first time after the third or fourth day, the question may arise as 
to the propriety of laying the abdomen open and reducing the 
intussusception by direct traction. For the details of the opera- 



310 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

tion of laparotomy, the reader must be referred to works on sur- 
gery. Briefly stated, it consists of making an incision in the 
median line of the abdominal wall ; opening the peritoneum ; 
finding the intussusception, and working it back at the neck in 
the same manner that a hernia is reduced. 

The practical results of the operation prove, beyond doubt, 
that there is very little to be expected from it. This is especially 
true in the case of infants less than a year old, in whom it has 
been invariably fatal. By its performance, too, the chance of 
recovery from separation of the strangulated intestine is lost. 

Upon this point, Prof. John Ashhurst, Jr.,* states : — 

" Inspection of the table (comprising 13 cases of laparotomy, 
5 in children), shows, in the first place, that no encouragement 
is afforded to repeat the operation in very young infants. The 
only instances in which it has been resorted to during the first 
year of life have all terminated fatally (Gerspn, Wells, Weinlech- 
ner). But when it is remembered that of Pelz's 162 cases (all 
occurring in children), no less than 91 were in infants less than 
a year old, it will be seen how large a proportion of cases must 
at once be put aside as unfitted for operative treatment. It is 
very true that the fatality of intussusception at this early age is 
enormous, the mortality being, according to Leichtenstein's 
elaborate statistics, no less than 86 per cent. But the case is 
very different from that, for instance, of an operation for imper- 
forate rectum ; for in this condition there is necessarily no hope 
but in an operation ; whereas, in the case of intussusception, ex- 
perience shows on the one hand that, even at this age, a certain 
number do recover without operation, and that, on the other 
hand, as might be expected, operative treatment is in such cases 
of no avail. 

" In the second place, the table shows that in what may be 
called acute cases, those, namely, in which in addition to symp- 
toms of obstruction there are evidences of strangulation, such as 
peritonitis and intestinal hemorrhage, a resort to operative inter- 

* American Journal of Medical Sciences, July, 1874. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 3II 

ference will be productive of no benefit. These cases are, on 
the other hand, as justly remarked by Mr. Hutchinson, precisely 
those in which there is most hope of recovery by sloughing of 
the invaginated portion. 

" There remains, then, a limited number of cases, in not very 
young infants, in which the symptoms are those of obstruction 
merely, without intestinal hemorrhage or peritonitis, and in 
which, when other measures fail, the question of operation may 
properly be considered." 

From additional cases collected since the compilation of the 
table above referred to, Prof. Ashhurst finds no data altering his 
previous conclusions. 

When separation and discharge of the invaginated segment of 
the intestine takes place, it is necessary to exert the utmost care 
lest the new-formed adhesions be broken down. The patient 
must lead a passive life ; the food must be readily digestible and 
restricted in quantity, and all farinaceous and fermentable arti- 
cles are to be excluded from the dietary. 

In chronic intussusception great reliance can be placed upon 
the free administration of opium and belladonna, with forced 
enemata ; or, in proper cases, insufflation of air, and as this con- 
dition generally occurs in late childhood, laparotomy, when other 
measures fail, may be undertaken with more hope of success. 



17. INTESTINAL WORMS. 

The common parasitic worms that find their habitat in the 
human intestines may be divided into two classes, each including 
several varieties, namely : — 

{Oxyuris vermicularis* 
Ascaris lumbricoides. 
Tricocephalus dispar. 

r Tcenia solium. 
Cestodes. } Tcenia saginata. 

I Bothriocephalic latus (rare). 



312 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Of these, the oxyuris vermicularis — small thread-worm — and 
the ascaris lumbricoides — long, round worm — are most frequently 
found in children. The taenia, or tape-worm, is uncommon be- 
fore the age of six or seven years. 



DESCRIPTION AND MODE OF ENTERING THE BODY. 

Oxyuris Vermicularis. — These worms are silvery-white in 
color and of small size ; the males being one-sixth of an inch, 
the females one-half an inch long. To the unaided eye they 
present the appearance of small, white threads. They inhabit 
the caecum and whole length of the colon, but are most abun- 
dant in the sigmoid flexure and rectum, where they derive nour- 
ishment from the faeces, and where, alone, they give rise to 
symptoms or evidences of their presence. 

Oxyures enter the body by direct passage of the ova into the 
mouth. They are introduced clinging to fruit and various 
articles of food, or are conveyed to the lips by the hands of the 
child previously used to relieve itching, occasioned by the pres- 
ence of the parasites in the neighborhood of the anus. Having 
entered the stomach, the embryos are liberated by the action of 
the gastric juice and pass into the small intestine, which they 
descend with the food, developing so rapidly that they become 
sexually mature by the time they reach the caecum. 

The eggs, as seen by the microscope, are 
-g^j- of an inch in length, ovoid and unsym- 
metrical. They are produced in great num- 
bers, each female giving birth to several 
broods, numbering from ten to twelve 

Egg of Oxyuris , , , , , 

Vermicularis. thousand, and they are extremely tenacious 

of vitality. 
Ascaris Lumbricoides. — This parasite has a certain superficial 
resemblance to the common earth-worm. It is cylindrical, taper- 
ing at both extremities, is reddish or brownish in color, has a 
body marked with fine transverse rings, and possesses a peculiar, 
disagreeable odor independent of the substance in which it lives. 





AFFECTIONS OF THE STOMACH AND INTESTINES. 313 

The head of the worm presents three prominent labial papillae 
surrounding the mouth, and the tail is conical. The male is 
from three to six inches in length and one-eighth of an inch in 
thickness, with an incurved tail and a penis consisting of a pair 
of slender, clavate, chitinous spicules, the ends of which protrude 
from a cloacal aperture at the root of the tail. The female meas- 
ures from six to fourteen inches in length and one-fourth of an 
inch in thickness. The genital aper- 
ture is situated on the ventral surface, 
near the anterior third of the body ; the 
ovarian tubes may be observed as long, 
tortuous canals, and the uterine tubes 
as short, straight canals ; the latter con- 
tain many millions of ova. The ripe 
ova are laid in the intestine, and are 

Egg of Ascaris Lumbricoides. 

expelled, with the stools, in great 

numbers, sometimes even in large masses. The eggs are -g-^- 
of an inch in diameter, and are oval, with a thick, elastic, 
brownish, double shell and nodulated surface. After expulsion 
from the rectum, they are very tenacious of life, remaining in a 
condition capable of development for several years. This is 
particularly the case when they find their way into water or moist 
earth. Here the embryos slowly develop. 

It is not positively known in what way children become in- 
fected with the parasite, but impure water is, without doubt, the 
medium. Recent experiments on both animals and men have 
demonstrated that infection cannot be directly produced by 
taking the recently laid, ripe ova into the stomach. It is prob- 
able, therefore, that the ova passed by an infected subject, after 
entering — through drainage or otherwise — moist soil or running 
water, and undergoing partial development, are eaten by some 
common, but unknown, minute aquatic animal. Within the 
bodies of these they are still further developed, so that, when 
the animalculi are ingested with impure drinking water, and 
the embryos liberated by the action of the digestive solvents, 




314 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the latter are in a position rapidly to assume their mature 
characters. 

Lumbrici inhabit the small intestine principally, though they 
frequently migrate. Their number in a single individual may 
vary from two to several hundreds. 

Tricocephalus Dispar. — The whip-worm, as this parasite is 
sometimes called, is yellowish-white in color, 
with the anterior half, or more, of the body 
attenuated in a hair-like manner. The male 
is about one inch and a half in length, has 
Egg of Tricocepha- the thick portion of the body enrolled, and 
a blunt tail. The female is two inches long, 
with a conical tail. The eggs of this worm are laid in the in- 
testine and voided with the faeces ; nothing is known of their 
subsequent history, or of the method in which the human being 
is infected. 

Whip-worms inhabit the lower end of the ileum, the caecum 
and the vermiform appendix, and feed on the intestinal contents. 
They are met with in small colonies, varying in number from 
two to twelve. Their occurrence is considered to be exceptional 
in this country, but this may be explained in two ways : first, 
as they are rarely voided with the faeces, like other worms, they 
escape ordinary observation ; and second, as their presence gives 
rise to no symptoms during life, few think of looking for them on 
the post-mortem table. 

TiENi^E infest children over the age of six years with almost 
the same frequency as adults. Of the three varieties, the tmtia 
saginata, beef tape-worm, and tcenia solium, pork tape-worm, are 
the most common, while of these two the former is met with in 
by far the greater number of cases. 

The tcenia saginata is a soft, yellowish-white, band-like worm, 
varying in length from six to twenty or more feet. The head has 
about the bulk of a yellow mustard-seed, is rounded quadrate, and 
provided with four hemispherical suckers. Between the head and 
body is a short, unsegmented, flattened neck, narrowest at its upper 




AFFECTIONS OF THE STOMACH AND INTESTINES. 315 

extremity and gradually broadening as it merges into the body. 
The latter is distinctly segmented. The first segments are several 
times wider than long, but become successively 
larger until the length exceeds the breadth two 
or three times ; their number may reach twelve 
hundred, and the largest measure from one- 
fourth to one-third of an inch in width, and a 
quarter to a full inch in length. The parasite Egg of taenia 

. . Sagtnata. 

is usually solitary. It inhabits the small intes- 
tine, in which position the segments, as they ripen, are sponta- 
neously detached, some having already expelled their burden 
of eggs (often numbering 35,000), others still laden. Both eggs 
and liberated segments then become mixed with the intestinal 
contents, pass downward into the colon, and are finally expelled 
with the faeces. The mature ova are brown, oval in shape and 
of minute size ; they have a thick inner shell, and an outer lon- 
gitudinally striated envelope. Each ova contains an embryo — 
a spherical or oval body — having at one pole three pairs of di- 
vergent, boring spiculae. 

In rural districts, it is a very common habit, with both adults 
and children, to stool in a fence corner, or other more or less 
secluded spot, at any time there is a call for evacuating the 
bowels. Should ova-laden tape-worm segments or liberated eggs 
be contained in the faeces so carelessly deposited, these are 
apt to be swallowed by cattle grazing in the neighborhood. 
Having once entered the stomach, the embryos, liberated from 
the eggs by the action of the digestive solvents, attach them- 
selves to the mucous membrane of the viscus, perforate it by 
means of their powerful boring apparatus, and, either directly or 
through the medium of the blood current, migrate into the tissues 
of the body, usually the muscles or liver. After attaining their 
destination, they become fixed and slowly undergo development, 
dropping the spiculae and being transferred into the larval form or 
scolex. The scolex consists of a head like that of the mature 
worm, with a neck terminating in a capacious cyst, within which 
the head and neck are inverted. In this form each parasite is 



31 6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

surrounded by a sack of connective tissue ; the new formation de- 
pending upon the presence of the larva, acting like an imbedded 
foreign body. The flesh, liver and other organs of cattle so in- 
fected are said to be "measly." Now should measly beef be 
taken into the stomach insufficiently cooked, or should it be 
administered raw — a frequent practice in the treatment of certain 
intestinal diseases — the parasite, during the process of digestion, 
is liberated from the investing connective tissue envelope, everts 
its head from the containing sack, attaches itself to the mucous 
membrane of the small intestine, feeds upon the intestinal con- 
tents, and, growing from its caudal extremity rapidly develops 
into a mature tape-worm. The time required for development 
has been proved by experiment to be less than two months, and 
the natural duration of life is very protracted. 

T^nia Solium. — This species of tape-worm enters the human 
body through the medium of measly pork. The methods of 
propagation and development are identical with those of the 
taenia saginata. In general appearance, also, the two worms are 
very sfmilar. The pork tape-worm, however, is white in color and 
broader and shorter, the usual length being between five and ten 
feet. The head, which presents the most prominent distinguishing 
features, is about the size of an ordinary pin ; it is spheroidal in 
shape, is surmounted by a blunt papilla, encircled by a double 
row of hooks, and, at the same time, has the four hemispherical 
suckers to be noticed in the beef tape-worm. The ova are some- 
what smaller but otherwise identical, the scolices, long known as 
Cysticercus celluloses, likewise possess the double row of hooks to 
the head, and in this way may be distinguished from the larvae of 
the other variety of taenia. The period occupied in development is 
about three months ; the length of life probably twelve years or 
more. 

As in the United States pork is but little used as food in com- 
parison with beef, and when used is thoroughly cooked, the 
difference in the frequency of occurrence of the two species of 
worms can be readily explained. In regard to this point, Prof. 
Leidy states : " Since the writer distinctly recognized the beef 



AFFECTIONS OF THE STOMACH AND INTESTINES. 317 

tape-worm, within the last twenty years, all the specimens of 
taeniae, from people of Philadelphia and its vicinity, that have 
been submitted to him for examination — perhaps in all about 
fifty — have appeared to belong solely to taenia saginata. The 
prevalence of this species with us is no doubt due to the common 
custom of eating underdone or too rare beef, while the pork tape- 
worm is comparatively rare, as with us pork is only used in a well- 
cooked condition." 

Symptoms. — These may be divided into two classes : general 
and special. 

The general symptoms are those always present, irrespective of 
the particular species of worm infecting the patient. They de- 
pend not so much upon the mere presence of the parasite, as 
upon the peculiar condition of the mucous membrane of the 
alimentary canal which accompanies and is, perhaps, essential to 
their development and existence. This condition is one of 
catarrh, with an excessive production of mucus, or, to give it a 
definite title, mucous disease ; consequently, the general symp- 
toms of worms are similar to those already studied under this 
head (p. 217). 

The patient wastes, and the face is pale or leaden in hue, dark 
circles surround the orbits, the eye-balls are sunken, the pupils 
dilated and the upper lip swollen. The skin generally is muddy, 
covered with dry, epidermic scales, and devoid of natural softness 
and elasticity. 

The lips and mucous membrane of the mouth are pale, the 
breath is offensive and the tongue is flabby, with the edges in- 
dented by the teeth and the dorsum covered with a thin, slimy 
coating, or it presents one or other of the conditions described 
(pp. 218, 220) as pathognomonic of mucous disease. There is 
often moderate hypertrophy of the tonsils and swelling of the 
lymphatic glands at the angles of the jaw. The appetite is ca- 
pricious, sometimes almost absent, and at others insatiable. Nau- 
sea, and acid eructations and vomiting are common. Constipa- 
tion is the usual state of the bowels ; occasionally there is 
tenesmus, with constant unproductive efforts at defecation, and 



318 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

there is a liability to attacks of diarrhoea, attended with great 
straining and the passage of black, slimy, ill-smelling motions. 
Free mucus may be discharged from the rectum, and, in girls, 
from the vagina. The abdomen is always distended, feels hard 
on palpation, and to percussion yields a tympanitic note. Con- 
stant complaints are made of pain in the belly, especially in the 
neighborhood of the umbilicus. Its character varies, being in 
some cases tearing or cutting ; in others, simply an uneasy, 
creeping sensation, and in others still, a sensation of coldness. 

The urine is frequently voided with pain and difficulty, and 
may have a turbid, milky appearance. 

The pulse is weak, altered in frequency and occasionally ir- 
regular; a harassing, paroxysmal cough may be present, and 
not uncommonly there is sighing, sobbing and hiccough. 

The child's temper is altered ; he becomes irritable or sullen ; 
his sleep is broken by bad dreams or night terrors ; and there 
are many and very diverse nervous manifestations, such as an- 
noying itching of the nose, temporary delirium or stupor, sudden 
blindness, loss of voice, squinting, fixation of the eye-balls, 
vertigo and general convulsions. 

These features, of course, are not equally marked in all cases, 
their degree depending upon the grade of intestinal catarrh. 

Special symptoms — those due directly to the presence of the 
worms — differ according to the species. 

The Oxyures occasion violent itching at the anus, especially at 
night, when they prevent sleep and lead to troublesome scratch- 
ing. This irritation, transmitted to the genitalia, combined with 
the constant application of the hands to these parts, produces 
erections in the male, and may induce the habit of masturbation 
in both sexes. Two conditions of the bowels are observed ; 
either forcible but ineffectual straining, often attended by prolapsus 
ani, or diarrhoea. Finally, the oxyures may, on inspection, be 
discovered moving about in the radiating folds of the anus. 

Occasionally, these parasites migrate into the vagina, uterus, 
urethra, oesophagus and stomach. When they occupy the vagina, 
they give rise to leucorrhcea. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 319 

Lumbrici occasion more or less pain in the umbilical region ; 
also vertigo, convulsions, and even chorea. The irritation of 
their presence may cause chronic diarrhoea, with scanty, offen- 
sive, thin, mud-colored stools, voided with much straining, and 
most numerous during the night. They often migrate into the 
stomach, whence they are quickly expelled by vomiting. Less 
frequently they pass into the common bile-duct and gall-bladder; 
also the nose, larynx, trachea, larger bronchi, vagina, urethra 
and bladder ; in each position giving rise to symptoms of irrita- 
tion. They have been found too, in abscesses communicating 
with the intestine, having escaped by entering a preexisting 
fistulous opening, or, perhaps, in some instances, by directly per- 
forating the gut. These abscesses usually occupy the abdominal 
wall in the umbilical or inguinal regions, or are seated in the 
substance of the liver. 

As already stated, the Tricocephalus dispar causes no special 
symptoms. 

Taeniae are attended by sensations of weight and gnawing in 
the abdomen ; occasional attacks of colic, and distention, par- 
ticularly of the umbilical region. With a huge appetite, there is 
progressive emaciation and general lassitude. A persistent head- 
ache is sometimes a feature, and there may be annoying cramps 
in the muscles of the legs and arms. 

Diagnosis. — While the occurrence of the symptoms detailed 
strongly indicate the presence of worms, the only positive proofs 
of their existence are the discovery of the parasites themselves or 
of their eggs in the stools ; their appearance, as in the case of 
oxyures, at the margin of the anus ; and their expulsion, as in 
the case of lumbrici, from the stomach in the act of vomiting. 
Therefore a purgative, by emptying the intestinal tract and ex- 
pelling some of the parasites, is the crucial test. 

In some cases the symptoms are severe enough to suggest tuber- 
culosis or tubercular meningitis ; though a mistake maybe readily 
avoided by bearing in mind this possibility and applying the test. 

Prognosis. — Intestinal worms rarely cause death. When a 
fatal termination does occur, it results from convulsions ; from 



320 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the consequences of the migration of the parasite into the bile- 
duct and air passages, or from some secondary affection ; proving 
dangerous because the strength of the frame attacked has been 
sapped by its guests. 

Treatment. — The diagnosis having been established, either 
by the spontaneous appearance of the worms or by their discov- 
ery after the administration of a dose of calomel or calomel and 
rhubarb, remedial measures must be directed to the accomplish- 
ment of two objects : ist, the expulsion of the worms ; and 
2d, the removal of the alkaline mucus — the essential nidus — 
and the restoration of the alimentary canal to its normal 
condition. 

ist. For expelling the parasites, the anthelmintic to be chosen 
depends upon the infecting species. 

Oxyures, as they inhabit the rectum, are within the reach of 
enemata, and are best treated by them. The object being to kill 
the worm, it is essential thoroughly to empty the lower bowel by 
an enema of warm water, immediately before injecting the para- 
siticide, so that the latter may come in contact with the mucous 
membrane, upon which the great mass of the worms lie. One 
or two medicated injections can be administered daily; they act 
best when cold, and their bulk should not be so large as to dis- 
tend the gut and lead to a quick return ; from one to two fluid- 
ounces is the proper quantity for a child of two years.* Liquor 
calcis ; common salt and water, in the proportion of one tea- 
spoonful to a pint ; a solution of castile soap, thirty grains to a 
pint of water \ or one of sulphuret of potassium, twelve grains to a 
pint ; oil of turpentine in milk ; half a teaspoonful to four fluid- 
ounces of pure olive oil ; and lard beaten up with water until it 
becomes liquid, all constitute good injections, the last two having 
the property of quickly relieving itching, in addition to their 
parasiticide action. In my experience, however, the injection 
of an infusion of quassia has been most uniformly successful. It 

* All of the succeeding directions for treatment are adapted to children of 
this age. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 32 1 

is best to order the quassia chips and have the infusion prepared 
in the nursery, thus: — 

R. Quassiae (rasped), gij. 

S. — Place in a porcelain vessel and pour on a pint of boil- 
ing water, macerate for two hours, then strain and 
inject two fluidounces once or twice daily. 

With children past the second year the proportion of quassia 
may be gradually increased to one ounce, at the age of seven. 

While employing enemata it is well to aid their action and re- 
lieve itching at the anus, by anointing the parts with some mild 
mercurial ointment, and at the same time pushing a little into 
the rectum. A good preparation of this kind is — 

R . Hydrargyri Chloridi Mitis, gr. lxxx. 

Unguenti Petrolei, gj. 

M. 
S. — Apply morning and evening. 

When there is intense rectal irritation, an injection of lauda- 
num and starch water (gtt. iij to fgj) and cold compresses applied 
to the fundament, give great comfort. 

Diarrhoea and tenesmus are to be overcome by the administra- 
tion of a teaspoonful of castor-oil, with five drops of paregoric 
once, twice or three times daily, according to circumstances. 
Should there be constipation, one teaspoonful of Husband's 
magnesia, or the appropriate dose of some other saline, must be 
given every morning until the symptoms disappear. Besides 
keeping the bowels regular, it is well to secure several free 
watery evacuations, at intervals of three days, for the purpose of 
dislodging any oxyures that may be inhabiting the upper part of 
the large intestine, and of clearing away accumulations of mucus ; 
to accomplish this, saline cathartics are to be selected. 

Against Lumbricoides a number of drugs bear an anthelmintic 
reputation. Of these, santonin, spigelia and chenopodium are 
the most efficient. To insure the greatest success, the patient 
for whom either of these medicines is ordered, must be placed 
on a restricted liquid diet, that the alimentary canal may be as 
27 



32 2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

empty as possible ; and during their administration the bowels 
must be kept active by cathartics, that the dead worms and the 
ova may be swept away. Broken doses of the purgative chosen 
can be combined with the anthelmintic, or an occasional full 
dose may be given during the course of the treatment. 

Santonin is almost tasteless, and when combined with sugar is 
readily taken by children ; it may be prescribed in the following 
ways : — 

B . Santonini, gr. vj. 

Sacchari, gr. xxx. 

M. et ft. chart. No. xij. 
S. — One powder morning and evening, each second dose 
to be followed by two teaspoonfuls of castor-oil or a 
purgative dose (gr. j) of calomel. 
Or— 

R . Santonini, gr. vj. 

Hydrarg. Chlorid. Mit, gr. vj. 

Sacchari, gr. xxiv. 

M. et ft. chart. No. xij. 
S. — One powder morning and evening. 

Santonin sometimes produces xanthopsia, or " yellow-seeing ; M 
this is of no importance and quickly disappears after the drug is 
discontinued. It is best, however, to advise the mother or nurse 
of the possibility of this occurrence. Occasionally, too, it in- 
creases the flow of urine and gives the fluid a reddish color. 

Spigelia is a very useful remedy, though as it simply narcotizes 
the worm it must always be administered in association with a 
purge. The officinal preparation, extractum spigeliae et sennas 
fluidum, is as good a combination as can be employed ; it may 
be given in doses of one teaspoonful three times daily. If it be 
desired to make success doubly sure, it is well to add santonin : — 

R . Santonini, . . . gr. iv. 

Ext. Spigelise et Sennse Fid., . f3J ss * 

Syrupi, f ^ ss. 

Elix. Simplicis, q. s. ad f J; iij. 

M. 

S. — Two teaspoonfuls three times daily. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 323 

Chenopodium is a very safe, non-irritant anthelmintic, being 
especially indicated when the evacuations are increased in num- 
ber, are liquid and contain mucus or blood. The volatile oil 
may be administered dropped upon a lump of white sugar, in 
doses of five drops three times daily. A purgative is then neces- 
sary, every twenty-four or forty-eight hours, or, for convenience, 
both remedies may be combined in a mixture: — 

R. Olei Chenopodii, . , f 3 ij. 

Olei Ricini, f g jss. 

Olei Cinnamomi, KX\v. 

Syr. Acaciae, . q. s. adfgiij. 

M. 
S. — One teaspoonful three times daily. 

Should there be reason to suspect ulceration of the bowel, five 
minims of oil of turpentine added to each dose of this formula 
will both improve the condition of the mucous membrane and 
increase the specific action. 

The only disadvantage possessed by oil of chenopodium is that 
it is not so acceptable to the taste or stomach as either santonin 
or the liquid extract of spigelia and senna. 

Whip-worms, when detected, can be removed by the same 
means as lumbricoides. 

Taeniae are the most difficult of the intestinal parasites to eradi- 
cate ; evacuations of many feet of segments are easily brought 
about, but reproduction steadily continues until the head is 
finally expelled. This portion is obstinate in its adherence to 
the intestinal mucous membrane, and being minute in size is 
easily shielded from the action of the parasiticide by the tena- 
cious mucus which is always secreted in excess when a tape-worm 
is present. 

It is essential, therefore, to diminish, or, if possible, entirely 
remove, this secretion, before commencing the actual treatment. 
For one week the child* must take the following prescrip- 
tion : — 

* The succeeding formulae are adapted to children of six years. 



324 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

U . Ammonii Chloridi, gij. 

Ext. Sennas Fid., f 5 vj. 

Inf. Gentianae Comp., q. s. adf^iij. 

M. 
S. — One teaspoonful before each meal. 

At the same time the diet must be restricted, and non-farina- 
ceous in character; for instance : — 

Breakfast at 8 a.m. — A tumblerful and a half (12 oz.) of milk, 
with two slices of gluten bread.* 

Luncheon at 12 m. — A teacupful (4 oz.) of milk. 

Dinner at 2.30 p.m. — A bowl (8-12 oz.) of beef, mutton, or 
chicken broth; two slices of gluten bread. 

Supper at 7 p.m. — Same as breakfast. 

For drink at dinner or between meals only pure filtered water 
in small quantities. 

At the end of the week's preparation one of the anthelmintics 
particularly adapted to this species of worm may be ordered. 
Of these there are several : — 

Oleoresin of male fern — oleoresina filicis — mentioned first, 
because most commonly used and generally efficient, should be 
given in one or two drachm doses, either floating upon a little 
(fgss) peppermint water or in a mixture, such as — 

R. Oleoresinse Filicis, fgij-iv. 

Syr. Acaciae, f ^ ij. 

Aq. Cinnamomi, q. s. adfgj. 

M. 
S. — Tablespoonful for a dose. 

The plan of administration has much influence on the issue. 
For the best result, the patient, unless much debilitated, must, 
upon the day on which the treatment is instituted, begin a fast 
after his dinner ; in the evening two fluidrachms of castor-oil 
should be given ; next morning, after the bowels have been 



* Gluten flour can be obtained in any of the larger cities, and is made into 
bread in the same manner as wheat flour. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 325 

thoroughly evacuated, a dose of fern \ and three hours later, a 
second dose of castor-oil. A few hours subsequently the worm 
will probably be expelled. During the interval, occasional sips 
of water may be allowed to relieve thirst. The nauseating taste 
of the oleoresin of fern may lead to its quick rejection from the 
stomach ; in such cases the viscus should be quieted by a few 
drops (3-5) of McMunn's elixir of opium, and a second dose of 
the anthelmintic administered after the lapse of half an hour. 

Kameela (Rottlerd) is another good remedy for tape-worm, 
possessing the advantage of being in itself an aperient, and 
hence doing its work without the aid of purgatives. The same 
period of absolute fasting is necessary, as when administering 
male fern, and on the morning of the day following the begin- 
ning of abstinence, two doses of fifteen grains of powdered ka- 
meela must be taken, at an interval of three hours. The drug 
may be exhibited suspended in syrup or in mucilage of acacia, 
a few drops of some aromatic oil being added in either case. A 
capital prescription, containing both kameela and male fern, is : — 

R. Kameelae, gr. xxx. 

Syr. Acacise, f 3 ij. 

Misce, et adde — 

Oleoresinae Filicis, f^j-ij. 

Aquae Cinnamomi, f§j. 

M. 
S. — To be taken in two doses at an interval of three hours. 

A formula very similar to this has been in long and most suc- 
cessful use at the Children's Hospital, Philadelphia. 

In some cases, oil of turpentine is very efficient, even when the 
remedies already mentioned fail. This may be given in one 
large dose, or in small doses frequently repeated. By the former 
method, from two to four fluid rachms are given in the morning 
after the usual fast, and followed in three hours by a dessert- 
spoonful of castor-oil, unless the bowels have been previously 
relieved. To carry out the latter, the following mixture may be 
used : — 



326 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

B . Olei Terebinthinse, 

Mellis, aa fgss. 

01. Menth. Pip., gtt. vj. 

Mucilag. Acacise, q. s. ad f liij. 

M. 

S. — Two teaspoonfuls every six hours. 

Every second day, preferably in the morning, two grains of 
calomel must be administered. 

Another useful drug is pumpkin seed ; this may be given in 
the form of an electuary, six drachms of the seeds being beaten 
up with sugar, and taken in one or two doses ; a brisk purge must 
be ordered after it. 

Koosso and its active principle, koossin, are recommended by 
some authorities. One drachm of the powdered drug suspended 
in water, or five or ten grains of koossin in capsule are the proper 
doses for a child of eight years. To prevent nausea, it is better 
to break the dose into two or four ; additional purgative is usually 
not required. 

For a long time the bark of the pomegranate root has been 
known as a remedy for " taenia," or tape-worm; but the diffi- 
culty of procuring it fresh, the short time it keeps good, and the 
unpleasant taste of the decoction, has greatly limited its use. 
Besides, it has been ascertained that its action is variable, accord- 
ing to the season of collecting, the age and vigor of the tree, 
etc. It is this uncertainty that compelled Professor Laboulbene, 
Member of the Academy of Medicine, who has made the cure of 
taenia a specialty, and who considers the bark of pomegranate 
root the best and most efficacious remedy, to say: " I wish that 
some one would discover and separate from the taenicide plants 
a sure alkaloid always identical, and that would act with cer- 
tainty, which is something we cannot obtain from pomegranate 
bark, or from old koosso, which is nearly inert. " 

Mr. Tanret has found this alkaloid, and for his discovery has 
been awarded the " Barbier Prize " by the Academy of Sciences. 
He calls it Pelletierine, in honor of the illustrious chemist, who, 
with Caventon, has made numerous discoveries in organic chem- 
istry of great benefit to humanity. 



AFFECTIONS OF THE STOMACH AND INTESTINES. 327 

Tanret's pelletierine has given the most satisfactory results in 
the hospitals where it has been tried, for instance, at the Marine 
Hospitals of Toulon, St. Mandrier, etc., and in Paris, St. Antoine, 
La Charite, Necker and Beaujon, etc. Dujardin-Beaumetz, 
Member of the Academy of Medicine, declared to the Society of 
Therapeutics, that he was successful in thirty-two cases out of 
thirty-three treated with pelletierine, and Professor Laboulbene 
was successful in every case in which he used it, fourteen in all. 

Pelletierine is dispensed in bottles containing the proper dose 
for an adult, and one dose is usually sufficient. For children 
from nine to twelve years, half the adult dose is sufficient. In 
administering the drug, certain preliminaries are indispensable 
to insure success. 

When pieces of tape-worm are or have been ejected within a 
short time after some other remedy has been taken without ex- 
pelling the head, pelletierine should not be taken until some 
pieces of the worm are again noticed. 

In the evening the patient must use a large laxative injection, 
and place himself on milk diet. The next morning mix the con- 
tents of a bottle with a glass of sweetened water, and administer 
at one dose ; three-quarters of an hour to an hour after, give one 
ounce of compound tincture of jalap, mixed with one-half a glass 
of sweetened water. For women, the dose should be reduced 
to 20 grammes, and for children a still further reduction is neces- 
sary. The purgative, compound tincture of jalap, is the best, 
but it can be substituted by any other cathartic. 

If the bowels are not relieved in a few hours after taking the 
purgative, then take either another purgative or an injection 
made of sulphate of sodium. A few minutes after having taken 
pelletierine there will be a sensation of giddiness, and the entire 
tape-worm will be passed from two to four hours after the remedy 
has been taken. 

After administering any anthelmintic, it is impossible to decide 
at once whether the tape-worm has been eradicated or not unless 
the head be discovered in the stools. The physician must not 
trust to the mother or nurse to find the head, but must look for 



328 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

it himself. The stools immediately following the action of the 
parasiticide must, therefore, be preserved until his visit; the 
chamber in which they are received being filled with water con- 
taining a small quantity of carbolic or salicylic acid. This is to 
be gently shaken in order to separate the worm from the faeces, 
and then allowed to stand for ten minutes; during which the 
parasite, from its greater specific gravity, sinks to the bottom of 
the vessel. Next, the supernatant liquid is poured off, the vessel 
refilled with water, and the process repeated until the fluid re- 
mains nearly colorless. Then the head, if present, is readily 
found. Should the head not be discovered, it is impossible, 
although all symptoms may disappear, to give a positive opinion 
as to complete expulsion until two or three months have passed. 
Any return of symptoms requires a second course of treatment. 
2d. The removal of the alkaline mucus and the restoration of 
the normal condition of the alimentary canal are to be accom- 
plished by the same attention to diet and the same therapeutic 
measures recommended when discussing chronic gastro-intestinal 
catarrh (p. 220). 



CHAPTER III. 

CASEOUS DEGENERATION AND TUBERCULOSIS OF 
THE MESENTERIC GLANDS— TABES MESENTERICA. 

Cheesy degeneration of the mesenteric glands, existing alone, 
or in association with tubercular deposit, is far from being a com- 
mon disease. The majority of cases occur after the third year, 
and under this age tabes mesenterica is rarely encountered. 

Morbid Anatomy. — The glandular lesions are identical with 
those so familiar in scrofulous conditions. 

Usually some of the mesenteric glands remain healthy ; and 
those involved — a variable number — do not present a uniform 
degree of alteration. A few are simply hypersemic and slightly 
swollen from an increase in the corpuscular elements ; some are 
increased in size and spongy in texture ; others, again, are en- 
larged to the size of walnuts, dense, dry and anaemic looking ; 
and still more are partially or completely converted into opaque, 
yellow, cheesy masses, and sometimes contain tuberculous 
deposits. 

The diseased glands may remain isolated, but often unite into 
an irregular mass of variable size. This mass is situated in mid- 
abdomen, rests upon the vertebral column, and is movable or 
fixed according to the freedom or involvement of the mesentery 
in the swelling. 

Further changes are softening of the caseous material, with 
suppuration and discharge through the gland capsule — an unusual 
event ; shriveling of the gland into a fibrous mass, through thick- 
ening and contraction of the trabecular of the reticulum ; and — 
quite commonly — a gradual hardening and shrinking by the ab- 
sorption of fluid and the deposition of earthy salts. 

Together with these changes, it is the rule to find scrofulous 
28 329 



330 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

lesions of the superficial lymphatic or bronchial glands, cheesy 
or tubercular deposits in the lungs, and ulceration of the mucous 
membrane of the intestinal canal. Sometimes, also, tubercular 
peritonitis and caseous and tubercular deposits in the liver and 
spleen are discovered at the post-mortem examination. 

Etiology. — As the disease always occurs in strumous subjects, 
the predisposing causes are the same as those leading to the pro- 
duction of that diathesis. 

The exciting causes are embraced under three heads — imperfect 
hygiene, disease of other organs, and infection through the milk 
of diseased cows. 

Children who live in filthy, over-crowded, dark and ill- 
ventilated houses, are much more likely to be affected than those 
born to more fortunate surroundings ; but of all hygienic factors, 
coarse, over-stimulating or bad food is the most potent for evil. 
This acts by irritating the intestinal mucous membrane and pro- 
ducing catarrh and follicular ulceration. 

Tubercular disease of the lungs, scrofulous disease of the cer- 
vical and bronchial glands or of the bones and joints, and tuber- 
cular ulceration of the bowels, are not only usual associates, but, 
no doubt, frequent causes of tabes mesenterica. In addition, 
measles and scarlet fever, from their tendency to induce inflam- 
mation of the mucous membrane of the bowels and glandular 
hyperaemia, must be ranked as exciting agents, and so, also, must 
difficult dentition and whooping-cough. 

Attention has recently been directed to the possibility of the 
transmission of tubercle to the intestinal tract by means of the 
milk of diseased cows. In support of this theory, Klebs has 
made a number of experiments, from which he draws the con- 
clusion that the use of the milk of cows having advanced phthisis 
always produces tuberculosis, which begins as an intestinal catarrh 
and extends to the mesenteric glands. 

Symptoms. — The signs elicited by physical exploration of the 
abdomen, and the symptoms arising from the presence of a large 
mass of glands are much more characteristic than the general 
features. The shape of the belly and the tension of its walls may 



CASEOUS DEGENERATION OF MESENTERIC GLANDS. 33 i 

be perfectly normal. Such is generally the condition during the 
earlier stages of the disease ; later, and particularly when there 
is intestinal ulceration, there is considerable distention. This is 
due either to the accumulation of flatus in the bowel or to the 
large size of the glandular tumor. In the first instance, the de- 
gree of prominence varies from day to day ; when marked, the 
wall is tense, percussion is tympanitic, and it is difficult or impos- 
sible to grasp the glands ; in the second, the enlargement is con- 
stant and greatest in and about the umbilical region ; here there 
is resistance to the palpating hand rather than tension ; the tumor 
is easily felt, and percussion over it gives a dull sound ; around it, 
a tympanitic one. The tumor varies in size from that of a hen's 
egg to that of a double fist; it is nodulated, hard, somewhat ten- 
der, slightly movable when small, and fixed when large. When 
of considerable size, the mass can readily be touched by placing 
the fingers on the umbilical region and pressing backward toward 
the spine. Otherwise, it is well to put one hand on either side 
of the abdomen and gently bring them together toward the 
median line, the patient being placed on his back with his shoul- 
ders and thighs elevated so as to relax the parietes ; by this 
method, it is possible to detect a tumor as small as a walnut. 

The secondary manifestations of the presence of a large mass 
of glands in the abdominal cavity are pains and cramps in the 
legs, due to pressure upon the nerves ; and oedema of the legs 
and distention of the superficial abdominal veins, from compres- 
sion of the great venous trunks. The veins are often very pro- 
minent, and ramify over the wall of the belly to join those of 
the thoracic wall, which are also distended. 

If the glands in the notch of the liver be enlarged, direct 
pressure is exerted upon the portal vein and ascites results ; this, 
however, is a very unusual symptom. 

Provided the naturally prolonged course of the disease be 
not abridged by tubercular or other complication, the tendency 
is for the glands to shrink and become calcareous. This change 
lessens the size of the tumor, diminishes the tension of the 



332 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

parietes, and, by relieving pressure, leads to the disappearance of 
the secondary derangements. 

Softening is another, but, fortunately, a rare termination. 
Adhesion may then take place between the gland and a loop of 
intestine, so that the softened matter is evacuated into the bowel 
without harmful result ; but should the discharge be directly 
into the peritoneal cavity, acute peritonitis is set up, and death 
soon follows. 

The general symptoms depend for their development upon the 
condition of the intestinal mucous membrane. Usually there is 
scrofulous ulceration, with or without general catarrh. 

If ulceration and catarrh be associated, the child wastes ; 
grows pale and feeble ; presents a haggard appearance : is fretful 
and peevish \ has a capricious appetite and much thirst ; com- 
plains of wandering pains in the abdomen, and is affected with 
« diarrhoea, attended by the expulsion of offensive, dark, watery 
stools, which, on standing, deposit flaky matter, mucus, and 
small, black blood clots. Sleep is restless, and at night the 
temperature rises one or more degrees above normal. 

When catarrh is absent, the bowels are often constipated ; the 
patient looks ill ; is pale and languid ; his muscles are flabby, 
and he has more or less flatulent pain in the belly ; but there is 
no marked wasting and none of the evidences of great impair- 
ment of general nutrition. 

Should there be no disease of the mucous lining of the bowels, 
flesh is retained ; the spirits and strength are good ; the appetite 
and bowels undisturbed ; the temperature normal, and there is 
nothing to show ill-health save some pallor of the skin. 

Diagnosis. — The only positive proof of the existence of 
tabes mesenterica is the detection, by palpation, of a glandular 
tumor. Particular caution must be given against the mistake, so 
frequently made, of attributing every case of abdominal dis- 
tention to disease of the mesenteric glands. Prominence of the 
belly is a frequent symptom in children, and in the vast majority 
of cases depends upon intestinal catarrh. In this condition 



CASEOUS DEGENERATION OF MESENTERIC GLANDS. 333 

there is imperfect digestion and assimilation of food, and, con- 
sequently, debility, affecting the muscles of the intestines as well 
as the system generally. Now, imperfectly digested food readily 
undergoes fermentation, with the production of carbonic-acid 
gas, and this distends the bowels ; the more so as they are want- 
ing in tone from the weakness of their muscular coat. Such in- 
flation of the gut must lead, of course, to a prominent abdomen, 
but one which is uniformly tympanitic on percussion, moderately 
soft and flaccid to the touch, and entirely free from the signs of 
enlargement of the mesenteric glands. 

Again, distention of the superficial abdominal veins is merely 
an indication of obstructed circulation in the deep venous trunks, 
and only becomes a symptom of importance in the diagnosis of 
tabes mesenterica when hepatic disease can be excluded. 

Even should a tumor be felt, the question arises whether it may 
not be an accumulation of faeces. In the latter there is no ten- 
derness ; the mass occupies the position of the transverse or de- 
scending colon, is oblong in shape, with its long diameter corres- 
ponding to the axis of the gut in which it is placed, and is so 
soft that it may be somewhat moulded by the pressure of the 
fingers. Should there be any doubt, an enema of warm water 
and soapsuds must be thrown into the bowel and retained for a 
few moments, by firm pressure upon the anus. When expelled 
this will bring away a quantity of light-colored, brittle matter, if 
the mass be due to faecal accumulation ; and the previously de- 
tected tumor will be found, on examination, to have disappeared 
or lessened in size. On the other hand, if the tumor be gland- 
ular, the expulsion of flatus and faeces, induced by the injection, 
only renders it still more prominent. 

The diagnosis must not be considered completed by the de- 
tection of the tumor, but must extend to the discovery or elimi- 
nation of the different complications — ulceration of the intes- 
tines, tubercular deposits in the lungs and tubercular peritonitis. 

Prognosis. — Caseation of the mesenteric glands is dangerous, 
but the danger does not spring from the glandular disease so 
much as from the affections that produce it, the conditions that 



334 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

accompany it, and the results that follow it. In regard to the 
latter, though, it may be stated that of all the glands in the body 
the mesenteric are least likely to be followed by ill consequences 
when diseased ; a fact due to their slight tendency to undergo 
softening. 

When the sole discoverable lesion is swelling of the glands, and 
there is no rise in the evening temperature nor marked impair- 
ment of nutrition, the hope of subsidence of the enlargement and 
ultimate recovery, may be reasonably entertained. On the con- 
trary, if there be wasting, diarrhoea and fever, indicating ulcera- 
tion of the bowels, secondary, perhaps, to chronic disease of the 
lungs, the prognosis must be grave. Again, the occurrence of 
tuberculous peritonitis renders the prospect most unfavorable. 

Treatment. — Much may be done in the direction of prophy- 
laxis by keeping a strict watch upon the stomach and intestines 
in scrofulous children, so as to remove any apparently trifling 
disorder as quickly as possible. Supplying good food, fresh, 
pure air and warm clothing, and maintaining the activity of the 
skin are also important preventive measures. 

After the disease is established, much can be accomplished by 
attention to the diet and general regimen. In regulating the 
diet, it is necessary to take into consideration the catarrhal state 
of the intestinal mucous membrane usually present, and the almost 
useless condition of, at least, a number of the mesenteric glands, 
and to select those articles which are absorbed in the stomach or 
taken directly into the blood vessels, without the intermediate 
action of the lacteals and mesenteric glands. The food must be 
sufficient to maintain the general strength, but not so abundant 
as to overtax the process of digestion. The following may be 
taken as an average daily schedule of both diet and regimen for 
a child of four years, in whom there is no excessive wasting or 
weakness : — 

On waking in the morning, say^at 7 a.m., a thin slice of dry, 
stale bread, and three fluidounces of hot veal broth. 

At 8.30 a.m. a cold bath, given in this manner : — being taken 
from bed, the whole body is briskly shampooed with a soft towel 



CASEOUS DEGENERATION OF MESENTERIC GLANDS. 335 

until the surface is aglow. The child is next made to stand in a 
tub sufficiently filled with hot water to cover his feet and ankles, 
and two gallons of cold water, containing an ounce of sea-salt or 
concentrated sea-water, are slowly poured over his shoulders. 
The skm is then thoroughly dried and rubbed until reaction is 
established ; the child is wrapped in a blanket and put back to 
bed for half an hour. On rising, the abdomen should be com- 
pletely enveloped in a flannel binder, and the body clad in 
woolen underclothing from head to foot. 

At 9.30 a.m., breakfast. — A soft-boiled egg and two slices of 
stale bread. 

From 10.30 a.m. to 12 m. — A walk or romp in the open air, 
in good weather. 

At 12 m., lunch. — Haifa dozen raw oysters or a bit of sweet- 
bread or fish, and a slice of dry, stale bread. 
* 

A.t 3 p.m., dinner. — Six fluidounces of beef, mutton or chicken 
broth ; a bit of minced roast beef, beef-steak, roast mutton, 
chicken, or wild fowl. A moderate quantity of spinach, stewed 
celery, boiled cauliflower, or other non-farinaceous vegetable, 
and one or two slices of dry, stale bread. No dessert except 
junket occasionally. 

At 7 p.m., supper. — Same as lunch, alternating the fish, sweet- 
bread or oysters. 

Nothing should be taken for drink but filtered water or, better 
still, good spring water. * 

When there is much emaciation and weakness, the morning 
bath must be omitted or substituted by a simple warm spong- 
ing ; and some stimulant, as a teaspoonful of old whiskey, should 
be given three times daily. 

Diarrhoea demands an exclusive liquid diet, and it is advi- 
sable to artificially digest the meat broths and milk, which must 
form the basis of this. 

The most useful drugs are cod-liver oil and the syrup of the 
iodide of iron, since the indications are to build up the general 

* Directions for Philadelphia. 



336 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

health and restore the glands to a healthy condition. The for- 
mer can be given as an emulsion with lactophosphate of lime in 
two-drachm doses three times daily, after eating, at the age of 
four years ; the latter in fifteen drop doses after meals. Often it 
is well to administer both preparations together. 

Locally, some good may result from the daily inunction of a 
weak mercurial or iodine ointment, for example : — 

R. Ung. Iodin. Comp., . . . gij. 

Ung. Belladonnae, gj. 

Ung. Aquse Rosae, ' . . g v. 

M. 

R. Ung. Hydrargyri, giij. 

Adipis, , . . gv. 

M. 

Of either a piece as large as a cherry may be rubbed into the 
skin over the tumor once every day. 

Other remedies are, of course, required to arrest diarrhoea, or 
to relieve the different complications that may arise. 

Should the circumstances of the patient permit, change of 
residence to some locality having an equable climate, a bracing 
atmosphere and a dry, porous soil, will greatly assist in effecting 
a cure. 



CHAPTER IV. 

AFFECTIONS OF THE LIVER. 

Hepatic diseases do not occur so frequently during childhood 
as in adult life. Fatty and amyloid changes are the most com- 
mon affections ; syphilitic disease, cirrhosis, tubercular deposit 
and parenchymatous inflammation stand next in the order 
named; while echinococcus is very rare, and cancer almost 
unknown. Jaundice, on the contrary, is often met with, but 
this condition, though a complex and striking one, is simply an 
indication of disease of the viscus itself, or of its excretory duct. 
Congestion of the organ is also common. 



i. JAUNDICE. 

Icterus, irrespective of the age at which it occurs, is character- 
ized by yellowness of the skin and conjunctivae, clay-colored 
stools and yellow-brown urine. During the first few days of life, 
especially after a difficult and tedious birth, there is apt to be 
intense congestion of the skin, followed, as the redness fades, by 
a brownish-yellow discoloration. This appears on the second 
or third day, and disappears by the tenth. 

It is not jaundice, for it is entirely independent of liver dis- 
order, and there is no yellowness of the conjunctivae, and no 
alteration in the faeces or urine. A form of true jaundice, how- 
ever, does occur in the newly-born, termed icterus neonatorum, 
which may be studied before describing the condition as it is 
seen in later childhood. 



337 



338 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

ICTERUS NEONATORUM. 

Both mild and dangerous types of this variety of jaundice are 
met with. 

The mild type occurs in infants prematurely born, or weak 
from other causes; in those early exposed to the depressing 
action of cold, dampness, and foul air, and particularly in 
those who are born partly asphyxiated after tedious labor. 
It is difficult to understand the exact method in which these 
causes act. Cold undoubtedly produces catarrh of the duodenal 
mucous membrane, and plugging of the bile-duct by mucus ; the 
others, the last especially, act, in all probability, by altering the 
hepatic circulation. At birth there is a sudden transference of 
the blood-supply from the umbilical to the portal vein ; a change 
— according to Frerichs — temporarily followed by comparative 
emptiness of the blood vessels of the liver; a diminution of 
vascular tension, and the passage of bile into the blood. Weber 
attributes the jaundice to pressure from congestion and oedema, 
the result of an arrest of the circulation in the umbilical vein 
before the establishment of respiration ; conditions present in 
infants born semi-asphyxiated. Birch-Hirschfeld has demon- 
strated that a dense areolar sheath surrounds the vessels in the 
notch of the liver and extends into the viscus along with the 
portal vein ; this becomes ©edematous and greatly swollen when 
there is venous obstruction in the liver during difficult parturition, 
and, by pressure, obstructs the flow of bile into the intestine. 

The grade of jaundice in this type varies considerably. Some- 
times the yellow discoloration is confined to the face, chest and 
back ; the conjunctivae are but lightly tinged ; the urine and 
faeces are unaltered, and after three or four days the trouble is at 
an end. In other cases, the yellowness extends to the abdomen 
and arms; the conjunctivae are distinctly yellow; the urine is 
dark and stains the diapers, but the stools still retain their natural 
color — golden yellow; the duration is about seven days. The 
best developed instances present universal and moderately deep 
discoloration of the skin ; the conjunctivae are very yellow ; the 



AFFECTIONS OF THE LIVER. 339 

urine brownish, and the stools clay-colored. With this degree 
of jaundice, there is malaise, loss of appetite, constipation, and 
enlargement of the liver ; the lower edge of the right lobe often 
extending below the costal border as far as the umbilicus. 

Occasionally, instead of constipation, there is diarrhoea, with 
moderate heat and tenderness of the belly, and a quick pulse, 
indicating severe intestinal catarrh. These cases recover after a 
fortnight or more, though occasionally diarrhoea arising and per- 
sisting in a feeble infant, is sufficient to determine a fatal issue. 

The Treatment is simple. The infant must be kept in a 
warm, well-ventilated room ; the activity of the skin must be 
maintained by bathing, and chilling prevented by proper cloth- 
ing. Constipation is to be relieved by fifteen or twenty drops of 
castor-oil, a soap suppository or an enema, and, if the skin be slow 
in resuming its normal color, it is well to prescribe an alkali, 
as: — 

R. Sodii Bicarbonatis, gr. xxxij. 

Aq. Menth. Pip., 

Syrupi, aa f^ss. 

Aquae, q. s. ad f^ij. 

M. 
S. — One teaspoonful three times daily. 

The grave type depends upon congenital malformation of the 
bile-ducts and gall-bladder; compression of the bile-ducts by 
syphilitic inflammation and growths, and umbilical arteritis and 
phlebitis. 

a. Congenital malformation is rare, but when it occurs is 
liable to affect several members of the same family in succession ; 
boys suffer twice as often as girls. There are a number of varie- 
ties : thus, the gall-duct may be converted into a fibrous cord ; 
the ductus communis may be contracted, obliterated or absent ; 
the gall-bladder may be rudimentary and the ducts absent ; or 
all the ducts may be wanting. Whatever the condition, the 
result is enlargement of the liver with cirrhotic change, more or 
less marked in proportion to the duration of life. The organ is 
dark green or almost black in color, feels unnaturally firm to the 



340 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

touch, and under the microscope shows an excess of connective 
tissue. 

From one to two weeks after birth the retained bile begins to 
give rise to jaundice ; this appears as a slight yellowness of the 
skin, and steadily grows more distinct, though it varies consider- 
ably in intensity from day to day \ at the same time, the con- 
junctivae are stained and the urine dark colored. After a day or 
two, the liver begins to encroach upon the abdominal cavity and 
rapidly enlarges; the spleen, too, increases in size, and these 
two lesions, together with flatulent distention of the bowels and 
occasional ascites, produce decided prominence of the belly. In 
spite of a uniformly good appetite, there is constant wasting. 
The bowels act sluggishly, the faeces are offensive, clay colored 
or dark green, from the presence of altered blood, and dilated 
haemorrhoidal veins can often be seen by inspecting the anus. 
Another frequent symptom is oozing of blood, either arterial or 
venous, from the umbilicus. This hemorrhage is capillary in 
nature, and usually begins at night, and soon after the fall of the 
navel string ; an event that occurs between the fifth and ninth 
day. It may be combined with bleeding from the nose, mouth, 
stomach or bowels, and is exhausting and always difficult to 
control. 

This form of jaundice ends in death. When umbilical hemor- 
rhage occurs, the course is short, varying from a few hours to six 
or seven days ; in other cases, life may be prolonged as many 
months, and death result from some intercurrent disease. In the 
latter class, the secreting elements of the liver are so far crippled 
by the constantly progressing cirrhosis that little bile is found, 
and the yellowness of the surface fades, or almost entirely dis- 
appears, before life ends. 

b. Syphilitic inflammation of the liver with its lesions and 
symptoms will be referred to in another place (see page 351). 

c. Inflammation of the umbilical blood vessels is due to blood 
poisoning. The infecting material in the infant is apparently 
identical with that producing puerperal fever in the mother, and 
is possibly caused by bacteria, as two forms of these — spherical 



AFFECTIONS OF THE LIVER. 341 

and rod-shaped — have been discovered in the blood of infants 
so affected. In consequence, the liver undergoes marked degen- 
erative changes ; the connective tissue about the portal vein and 
its branches becomes swollen and presses upon the bile-ducts, 
and from this, as well as from alterations in the crasis of the 
blood, jaundice results. 

Discoloration of the skin makes its appearance a few days after 
birth and rapidly increases ; the urine is very dark, and the stools 
are scanty and passed at long intervals. The face is livid and 
pinched ; the hands and feet are purple ; petechias appear under 
the skin ; the abdomen is distended by flatus and by enlargement 
of the liver and spleen ; there is tenderness with fluctuation on 
palpation, and blood or bloody pus exudes from the umbilicus. 
The tongue is dry, there is little appetite, and the stomach re- 
jects what food is taken, together with quantities of greenish 
mucus. Pyrexia is noticeable from the beginning, and becomes 
more marked as the disease progresses ; the pulse is quick and 
the breathing hurried. 

The course is always short, and the invariably fatal termina- 
tion may be preceded by convulsions and coma. 

Treatment in either variety is most unsatisfactory ; little can 
be done beyond the employment of measures to maintain the 
vital forces as long as possible. Umbilical hemorrhage may be 
arrested by the application of Monsel's solution, or, if this fail, 
by inserting two hare-lip pins through the skin at the root of the 
navel and twisting a ligature tightly around them in the form of 
a figure of eight. 

Syphilitic inflammation demands appropriate constitutional 
remedies, and in pyaemic cases the abdominal tenderness must be 
relieved by warm fomentations and sedative applications. 



ICTERUS IN OLDER CHILDREN. 

Jaundice in late infancy and childhood usually depends upon 
catarrh, extending from the mucous membrane of the duodenum 
into the ductus communis ; sometimes it is due to plugging of 



342 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

the duct by inspissated bile ; and, again, to occlusion by the 
entrance of a lumbricoid worm. Certain structural lesions of the 
liver, poisoning by phosphorus and miasmatic influences, also 
produce it. 

Catarrhal jaundice — the only form necessary to consider in 
this connection — presents the features so common to, and so 
characteristic of, the same condition in adults. Briefly stated, 
there is more or less yellow or brownish-yellow discoloration of 
the skin, with troublesome itching, yellowness of the conjunc- 
tivae, porter-like urine, and clay-colored stools, devoid of the 
natural faecal odor. Other symptoms are anorexia, craving for 
acid drinks, a yellow-furred tongue, disordered digestion, list- 
lessness, slowness of the pulse, slight reduction of the surface 
temperature, and disturbed sleep. The liver may be somewhat 
enlarged, projecting two inches or more below the costal border, 
and tender, or even painful, on pressure. The result is always 
favorable, and the duration rarely longer than two or three weeks. 

Treatment. — Warm clothing, daily bathing followed by 
gentle friction to promote the activity of the skin, and a diet 
based on the same plan as for intestinal catarrh, are the first 
requisites. 

The medicinal treatment can be begun by a moderate dose of 
calomel, followed by a saline; but if a laxative be requiredlater, 
the drugs that stimulate the secretion of the liver and act upon 
the upper bowel must be excluded, and those selected which 
affect the lower segment, as aloes and castor-oil. 

Duodenal catarrh — the causal factor — is most speedily removed 
by alkalies. Four fluidounces of some saline water, as Kissingen 
or Vichy, should be drunk at each meal, and the following mix- 
ture taken : — 

R. Ammonii Chloridi, ., . . gij. 

Aq. Menth. Pip., fg iij. 

M. 
S. — One teaspoonful, diluted, three times daily after meals, 
for a child six years old. 

Nux vomica is also useful, and two or three drops of the tinc- 
ture may be administered thrice daily before eating. 



AFFECTIONS OF THE LIVER. 343 

2. CONGESTION OF THE LIVER. 

Congestion of the liver is quite common, especially in children 
of four years of age and upward. 

Morbid Anatomy. — There is an increase in the size, weight 
and density of the organ, and its peritoneum is tense and shining. 
On incision, blood flows freely, and the section presents a 
mottled or "nutmeg" appearance, partly from dilatation of the 
intra-lobular veins and partly from staining of the cells by 
retained bile. In long-standing cases, those due to cardiac disease, 
for example, the cells in immediate proximity to the dilated 
intra-lobular veins atrophy; those near them are stained with 
bile, and those most distant undergo fatty degeneration. In time 
the atrophied cells disappear ; their place is taken by connective 
tissue, which shrinks and produces a cirrhotic condition, the 
surface of the liver becoming granular and the capsule thickened. 

Etiology. — Even in health the amount of blood in the 
hepatic vessels varies from time to time, and there is always a 
temporary increase during the process of digestion. This nor- 
mal hypersemia readily becomes abnormal and continuous when 
there is habitual over-feeding ; when the food is highly spiced 
and too stimulating; and when insufficient exercise is taken. 
Congestion is often produced by chills, whether resulting from 
exposure to cold or from the poison of malarial fever, since, in 
either case, the blood is driven from the surface to the interior 
of the body. Again, cardiac disease, by obstructing the return 
of blood from the lung and overfilling the vena cava and portal 
vein, is an active cause. 

Symptoms. — The skin is sallow, or together with the conjunc- 
tivae distinctly jaundiced. There is malaise; headache; a yel- 
low, furred tongue ; anorexia ; nausea ; relaxed bowels with clay- 
colored, offensive stools, and dark-colored urine loaded with 
lithates. Pain in the right hypochondrium is usually present, 
and, as this is increased by turning upon either side, the patient 
maintains a dorsal position ; there is also tenderness in this 
region, and the suffering is increased by coughing or deep 



344 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

breathing. On palpation, the right lobe of the liver can be 
detected, extending two or three inches beyond the costal border, 
while at its edge is felt the gall-bladder distended into a pyriform 
tumor of variable size. At the same time the upper limit of 
percussion dulness begins in the third interspace, or at the level 
of the third rib, instead of the fourth interspace, as in health. 

Should the congestion depend upon heart disease, albuminuria 
and oedema of the feet and legs are associated. 

Diagnosis. — Many instances of disordered digestion, with the 
expulsion of putty-like, undigested material from the bowels, 
are attributed to congestion of the liver, when in reality the 
gastro-intestinal tract alone is at fault. Such a mistake can be 
avoided, if it be remembered that to establish the existence of the 
hepatic disease it is necessary to have enlargement of the organ, 
with pain and tenderness ; jaundice and clay-colored, offensive 
stools; combined with disturbance of the functions of the 
stomach and intestines. 

Extension of the liver a finger's-breadth or more, below the 
costal border, does not absolutely indicate enlargement, since 
this often occurs without disease, in short-chested children, and 
in those whose chests are contracted and deeply grooved by 
rickets. Downward displacement and apparent enlargement may 
also be caused by pleuritic and pericardial effusions, and by em- 
physema of the lungs. On the other hand, an enlarged liver 
may be completely under cover of the ribs, for, in addition to 
being normally high in the thorax, it may be pushed upon by a 
collection of fluid or a growth in the abdominal cavity, or drawn 
up through the shrinking of a collapsed or indurated lung. It 
is essential, therefore, to fix the position of the upper limit by 
percussion, as well as the lower edge by palpation, before forming 
a conclusion. 

Prognosis. — The course of the affection is short, and there is 
no danger unless the child be greatly reduced by previous ill- 
health, or there be cardiac disease. In the latter case, the dura- 
tion and result correspond to, and depend upon, the gravity of 
the heart lesion. 



AFFECTIONS OF THE LIVER. 345 

Treatment.— The child may be put to bed, or, if not ill 
enough to be so confined, should be kept within doors. The abdo- 
men must be protected by a flannel binder or a layer of cotton 
batting covered with oiled silk, and the skin kept active by a 
daily warm bath, administered, in walking cases, just before 
retiring to bed. Too much food of any kind is bad ; meat and 
highly-seasoned dishes are to be excluded from the diet ; and it 
is best not to extend the list beyond milk, mutton or veal broth, 
fish, bread and plain light puddings, as rice and milk. 

In the beginning, a child of six or eight years should get the 
following powder : — 

R • Hydrargyri Chlorid. Mit., gr. lj. 

Pulv. Ipecacuanhas, gr. ss. 

Sacchari, gr. v. 

M. et ft. chart. No. j. 
S. — To be taken in the evening and followed, next morning, 

by a teaspoonful of magnesia. 

Subsequently, five grains of chloride of ammonium should be 
given after food, and a small tumbler (five fluidounces) of Vichy 
taken with each meal. 

Aloes and the salines are the best remedies to relieve consti- 
pation during the course of the attack. 

In cardiac cases, treatment must be directed chiefly to the 
heart ; and in those due to malarial poisoning, antiperiodics are 
of little avail until the hepatic congestion is relieved. 

When convalescence is established, regular exercise in the open 
air must be insisted upon and a plain diet maintained. Change 
of air is often most useful to break up the " bilious habit." 
29 



346 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

3. FATTY LIVER. 

This condition presents itself- in two distinct forms, namely, 
fatty infiltration and fatty degeneration. 

FATTY INFILTRATION. 

In fatty infiltration, the quantity of fat in the hepatic cells is 
greatly increased without any alteration in the walls of the cells. 

Morbid Anatomy. — The liver is increased in all its dimen- 
sions, its surface is yellowish and oily, its margins rounded and 
its texture doughy. On section, the cut surface is distinctly 
yellow, mottled with brownish-red spots, and if a bit be put under 
the microscope, abundant granules and globules of fat are seen. 

Etiology. — One cause of fatty infiltration is an excess of fari- 
naceous food. Then the deposition is physiological and transi- 
tory, the excess of hydrocarbons supplied from without being 
deposited in the liver in the form of fat. The second cause is 
chronic, exhausting disease, such as tubercle, scrofula, rickets, 
caries of bone, intestinal catarrh and syphilis. Here the fat is 
absorbed from the subcutaneous and other fat-containing tissues 
of the body. 

Symptoms. — It is only in well-marked cases that these are 
developed. An increase in the bulk of the liver with a rounded, 
inferior margin may be detected by percussion and palpation; 
but this is frequently impossible on account of the tendency the 
organ has, from its softness, to fall away from the abdominal 
wall. There is a sense of weight in the right hypochondriac 
region and disturbed gastro-intestinal function, due to portal 
obstruction. Jaundice and ascites are absent, and there is 
neither pain nor tenderness over the viscus. 

The Diagnosis is not difficult when enlargement, softness and 
blunting of the edge of the viscus can be detected by examination. 

The Prognosis depends upon the cause rather than the degree 
of change; occurring in the course of a protracted, wasting dis- 
ease, fatty infiltration shows dangerous impairment of nutrition. 



AFFECTIONS OF THE LIVER. 347 

Treatment. — Beyond a rigid exclusion of farinaceous and 
fatty foods from the dietary, all remedies must be directed to the 
relief of the originating disease. 



FATTY DEGENERATION. 

Fatty degeneration is a much rarer lesion in children than fatty 
infiltration. 

Morbid Anatomy. — The liver appears normal to the unassisted 
eye, but with the aid of the microscope the cells are found to be 
filled with minute protein or fatty granules, and tend to frag- 
mentation and destruction. The whole, or only isolated por- 
tions of the viscus, may be changed in this way. 

Etiology. — The lesion is produced by acute affections, as 
measles, variola, scarlatina and typhoid fever ; by chronic, 
exhausting diseases, as tubercle, scrofula and rickets ; and by 
accidental poisoning with arsenic or phosphorus. 

There are no characteristic symptoms, the result is invariably 
unfavorable, and no special indications for treatment are pre- 
sented. 



4. AMYLOID LIVER. 

This lesion is moderately common in childhood, and usually 
occurs as a factor of general amyloid degeneration. 

Morbid Anatomy. — The disease consists in a more or less 
complete infiltration of the cells by a peculiar translucent, 
refracting substance, possessing the property of fixing iodine and 
assuming a mahogany-brown color, which, on the application of 
sulphuric acid, changes to green, blue, violet or red. The infil- 
tration begins in the hepatic arterioles and capillaries, and at 
first is limited to the middle zone of the lobules ; thence it 
extends to the periphery and centre, destroying the normal ele- 
ments of the cells and converting them into irregularly shaped, 
glassy-looking blocks. Fatty infiltration is often associated. 
Uniform enlargement ; increased density ; yellowish-gray color ; 



348 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

smooth, shining peritoneum; thin edges, and the exposure, on 
section, of dry, homogeneous, glistening surfaces, are the gross 
characteristics. 

The spleen, kidneys and lymphatic glands are often similarly 
altered, and sometimes the mucous membrane of the stomach 
and intestines. 

Etiology. — Amyloid degeneration of the liver is always pro- 
duced by some chronic disease, attended by suppuration and 
purulent discharge. Empyema with a fistulous opening in the 
chest-wall ; dilated bronchi with copious muco-purulent expec- 
toration ; scrofulous abscess ; chronic pulmonary tuberculosis ; 
suppurative diseases of the bones and joints, and constitutional 
syphilis, are the most frequent causes. It occurs at any age, but 
is more frequent after the fifth year, and in boys than girls. 

Symptoms. — There are few rational symptoms other than those 
belonging to the originating disease. Tenderness and pain in 
the hepatic region are absent, and so, too, are jaundice, disten- 
tion of the superficial abdominal veins and ascites ; except the 
glands in the fissure of the liver be coincidently enlarged by 
waxy deposit, when, from pressure upon the portal vein and bile- 
ducts, the last three phenomena may be developed. The patient 
complains of weight, discomfort in the right hypochondrium, 
and is weak, wasted and anaemic, with pale, sallow skin, clubbed 
fingers and oedematous feet and ankles. When the kidneys are 
involved, the urine is increased in quantity, has a low specific 
gravity (about 1014), is pale, lemon colored, and contains albu- 
men, and, at times, hyaline tube casts. Dropsy of the extremi- 
ties is due in great part to this complication. If the stomach 
and intestines be implicated, there is a tendency to vomiting 
and diarrhoea. 

Physical examination yields very characteristic signs. The 
abdomen is prominent, especially over the upper third, and both 
percussion and palpation show that the liver is greatly and uni- 
formly enlarged. The upper margin of dulness is higher, by an 
inch or more, than normal ; while the lower edge of the right 
lobe, somewhat blunted, but perfectly well defined, can often be 



AFFECTIONS OF THE LIVER. 349 

felt as low down as the level of the umbilicus. The portion 
uncovered by the ribs feels very dense and firm, and perfectly 
smooth, except where broken by the natural fissures. 

The spleen can often be detected projecting as a hard mass 
from beneath the left costal border. The absence of enlarge- 
ment, however, is no proof against the existence of amyloid 
change in the organ ; in about half the cases there is no alteration 
in size. 

In course, the disease is always slow. 

Diagnosis. — This is readily made from the physical signs 
furnished by the liver and spleen ; the absence of jaundice and 
ascites ; the previous history of cachexia and suppuration ; the 
character of the urine; the anaemia, and the gastro-intestinal 
symptoms. 

Congestion of the liver with consequent enlargement has a 
different clinical history, rarely occurring in cachectic or anaemic 
cases. A fatty liver, while large, is soft and yielding to the 
touch, and is unattended by increase in the size of the spleen or 
albuminuria. 

Prognosis. — The prospect of ultimate recovery is better in 
children than in adults, for, provided the cause of the degenera- 
tion can be removed, it is quite possible for the liver to return 
to its natural dimensions and to an apparently healthy condition, 
through the active reparative power always present in early life. 
Nevertheless, amyloid change in the liver adds greatly to the 
danger of the originating disease, and is fatal in most cases. 

Treatment. — It is almost needless to state that attention must 
first be given to the removal or amelioration of the cause. It is 
much more difficult to cure the disease when once developed, 
than to prevent it by checking chronic suppuration, removing 
carious bone, healing diseased joints, energetically treating con- 
stitutional syphilis, and building up the health in cachectic 
subjects. 

To combat the disease itself, the diet must be as nutritious as 
the activity of digestion will permit; a moderate quantity of 
alcoholic stimulants must be taken daily; the child must be 



35 O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

properly clothed, to prevent chilling, and must live as much as 
possible in the sunlight and open air, or, if confined to the house, 
in a light, airy room. Alkalies, iron and iodine are the most 
useful drugs. 

Of alkalies, chloride of ammonium is the best, and it may be 
given in combination with a bitter, as: — 

R. Ammonii Chloridi, gij. 

Inf. Gentianse Comp., f g iij. 

M. 

S. — One teaspoonful four times daily at the age of six years. 

It is often well to combine iron with the ammonia salt, for 
example : — 

R. Tr. Ferri Chloridi, . fgj. 

Ammonii Chloridi, gij. 

Inf. Calumbse, q. s. ad f^iij. 

M. 

S. — One teaspoonful three times daily. 

Another good way of administering iron is in the form of a 
modified Basham's mixture : — 

R. Tr. Ferri Chloridi, fgj. 

Acid. Acetici dil., f ^ jss. 

Liq. Ammonii Acetatis, f g x. 

Elix. Aurantii, f^ v - 

Syrupi, fgj. 

Aquae, . . . q. s. ad fgvj. 

M. 
S. — One tablespoonful four times a day. 

This formula is particularly useful when there is kidney com- 
plication with oedema. 

Iodine is most efficient if there be a syphilitic taint; it maybe 
given in the form of iodide of potassium, five grains or more 
three times a day, with a bitter infusion ; or liquor iodinii comp. 
can be employed in doses of two drops, well diluted, thrice 
daily. 

Complications must be met as they arise. Vomiting, by ice, 



AFFECTIONS OF THE LIVER. 35 1 

cold Apollinaris water, bismuth and counter-irritation to the 
epigastrium ; diarrhoea, by vegetable astringents, with small doses 
of opium ; and dropsy, by diaphoretics and diuretics. 



5. SYPHILITIC INFLAMMATION OF THE 

LIVER. 

Syphilitic hepatitis is frequently encountered in the newly- 
born, though rare in more advanced childhood. 

Morbid Anatomy. — The liver may be the seat of acute swell- 
ing, which, without showing marked gross alteration, is associated 
with a diffused growth of connective tissue elements ; again, there 
may be a localized gummatous change ; and, finally, the inflam- 
matory process may be confined to the septa — peripylephlebitis 
syphilitica. The proliferation of connective tissue takes place 
both between the hepatic islands and in their interior, thus dif- 
fering from cirrhosis, where the increase is only between the 
lobules. When jaundice occurs, the small bile-ducts are thick- 
ened and occluded by epithelial cells, and the organ is enlarged, 
and brownish-yellow in color. 

Symptoms. — In mild cases these are few and uncharacteristic ; 
in those that are grave there are jaundice, ascites, hemorrhage 
from the umbilicus and intestines, ecchymosis of the skin, sub- 
normal temperature, rapid wasting, and often syphilitic lesions of 
the skin and mucous membranes. On abdominal exploration, 
the liver is found to be enlarged and hard, and the spleen in- 
creased in size. 

Diagnosis. — The early age, the history of an inherited taint, 
the association of enlargement of the liver with jaundice and 
ascites, make this a matter of little difficulty in cases that are at 
all marked. 

Prognosis is unfavorable, though the opinion must rest upon 
the degree of cachexia. Goodhart states that all of his cases 
proved remarkably amenable to mercurial treatment, but this 
does not correspond with the experience of other observers. 



352 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

Should deep jaundice, ascites and hemorrhage occur, death is 
the almost invariable end. 

Treatment. — As in other syphilitic affections, mercurials 
must be followed by tonics. One-eighth of a grain of calomel, 
or one grain of mercury with chalk; may be administered morn- 
ing and evening, or ten grains of mercurial ointment may be 
rubbed into the skin once a day, either directly by the fingers of 
the nurse, or by being smeared upon the flannel binder. 

After the liver has been reduced in bulk and other manifesta- 
tions of the poison are under control, syrup of the iodide of iron, 
in two-drop doses three times daily, is the most efficient tonic. 

Iodide of potassium is also useful; it acts best when combined 
with chloride of ammonium, as : — 

R . Potassii Iodidi, gr. xxiv. 

Ammonii Chloridi, . . gr. xxxvj. 

Syrup. Sarsaparillse Comp., . f^ss. 

Aquae, q. s. adfgiij. 

M. 
S. — Teaspoonful three times daily for an infant of one month. 

In those fortunate instances that yield to treatment, splenic 
enlargement disappears less rapidly than that of the liver, and 
requires the daily application of compound iodine ointment di- 
luted in the proportion of one part to seven of lard. 



6. CIRRHOSIS OF THE LIVER. 

In childhood, cirrhosis must be classed among the uncommon 
diseases of the liver ; the fact of its occasional occurrence, how- 
ever, has been abundantly proved by post-mortem examinations. 

Morbid Anatomy. — There are two forms, namely, the atro- 
phic and the hypertrophic. 

In atrophic cirrhosis or hob-nailed liver, the organ is con- 
tracted and dense in texture, with nodulated surfaces, thin edges 
and thickened capsule ; on incision the cut surface is grayish- 



AFFECTIONS OF THE LIVER. 353 

yellow in color, and traversed by a distinct fibrous network. 
The lesion begins as a chronic inflammatory condition of 
the branches of the portal vein, and consists of a rapid devel- 
opment of embryonic cells, with subsequent conversion into 
fibrous tissue. The new formed tissue follows the branches of 
the portal vein within the substance of the gland ; extends into 
the inter-lobular spaces and forms meshes of variable size, but 
always embraces several lobules. Some enlargement may attend 
the primary formation of embryonal tissue, but the shrinking of 
cicatricial contraction invariably follows ; the cells become flat- 
tened and atrophied ; there is a marked reduction in size, and 
the circulation in the hepatic portal vessels is greatly obstructed. 
The smaller bile-ducts are little affected, and blood for the nour- 
ishment of the organ and for the formation of bile is carried by 
vessels developed in the neoplasm. 

In hypertrophic or biliary cirrhosis, the liver is usually en- 
larged, perhaps to twice its normal dimensions. It has a smooth 
surface, a thin edge, and its section is orange-yellow or green. 
The fibroid growth begins around the intra-lobular branches of 
the bile-duct, and envelops and isolates separate lobules ; it fol- 
lows the ramifications of the bile-ducts ; is more diffused than in 
the atrophic form, and denser and thicker in some portions than 
in others. The portal circulation is not necessarily embarrassed, 
but the biliary ducts are obstructed and dilated, and have their 
epithelial lining increased in thickness. 

In both forms there is enlargement of the spleen, and in some 
cases there is an association of the characteristic lesions. 

Etiology. — The causes are, as yet, ill-determined. Alcoholic 
excess, the prime factor in adults, is, of course, inoperative in 
children, except in very rare cases; some authorities, however, 
are inclined to look upon the intemperance of parents as, at least, 
a predisposing element, and regard the vice of drunkenness as 
one of the sins of the fathers visited upon their offspring. Con- 
genital deficiency of the bile-duct is always attended by cirrho- 
sis. Constitutional syphilis frequently, and general tuberculosis 
occasionally, precede it. It is not limited to any sex or age, 
30 



354 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

though more frequent in boys than girls, and oftener met with 
between the sixth and twelfth years than at an earlier period of 
life. 

Symptoms. — Both forms are preceded, for a variable time, by 
the evidences of defective nutrition, but, as might be expected 
from the different pathological conditions, the after symptoms 
are dissimilar. With atrophic cirrhosis the child is peevish and 
restless, sleeps badly at night; has indigestion, flatulence and 
costive bowels; a pale and pasty complexion, and dark circles 
about the eyes. His muscles grow flabby, there is general wasting, 
and the urine is thick with lithates, or is very acid and deposits 
a brick-dust sediment of uric acid. After these symptoms have 
been present for a period — usually a long one — pain in the region 
of the liver and ascites are developed. With the ascites there is 
prominence of the abdomen, dilatation of the superficial abdomi- 
nal veins, and, at first, enlargement of both the liver and spleen. 
Soon the liver begins to decrease in size, but the spleen continues 
to enlarge.* Weakness and loss of flesh are progressive; the 
ascites becomes more marked ; there is oedema of the feet and 
legs ; the skin is sallow, and harsh to the touch ; the tongue is 
coated ; the appetite impaired ; the stomach irritable ; the bowels 
alternately confined and relaxed ; there is abdominal pain ; 
hemorrhoidal swellings are noticeable ; hemorrhages occur from 
the stomach, bowels, nose and gums, and petechial spots appear 
beneath the skin. 

The course is prolonged and interrupted by periods of apparent 
improvement, during which the ascites diminishes and the patient 
is free from discomfort, and in some degree recovers health and 
spirits. 

General dropsy, severe diarrhoea or hemorrhages indicate that 
the end is near. Sometimes intercurrent inflammation of the 
pleura or lungs is the direct cause of death. 

* If ascites be extreme, it is often difficult to detect the spleen by palpation 
when the patient is in the ordinary dorsal position, or on the right side. In 
such cases, placing the patient upon the hands and knees entirely removes 
the difficulty. 



AFFECTIONS OF THE LIVER. 355 

In hypertrophic cirrhosis, the skin, conjunctivae and urine are 
deeply stained by bile, and the stools, which vary greatly in 
number and consistency, are clay-colored. The liver and spleen 
are enlarged, but there is no distention of the superficial abdominal 
veins, and no ascites. At times the jaundice and enlargement of 
the liver increase rapidly; then there is moderate fever, with 
much pain in the right hypochondrium. As the end approaches 
the pulse becomes markedly irregular ; the tongue grows dry and 
brown ; the teeth are covered with sordes j there is complete 
anorexia ; rapid wasting ; bleeding from the gums, from the 
stomach or beneath the skin ; apyrexia, drowsiness, stupor, and, 
finally, convulsions. The course is more rapid than in the 
former variety, but still protracted. Should both forms exist 
together, there is a combination of jaundice, ascites and disten- 
tion of the veins in the abdominal wall. 

Diagnosis. — The characteristic features of atrophic cirrhosis 
are diminution in the area of liver dulness, following a temporary 
increase in the bulk of the organ ; enlargement of the spleen ; 
dilatation of the superficial veins ; ascites ; hemorrhoids ; a dry, 
earthy skin, and gastro-intestinal hemorrhages, occurring, with- 
out fever, in a child who has a history of prolonged ill-health, 
feebleness and wasting. 

The second and more uncommon variety, while having very 
much the same preliminary history, presents as its distinguishing 
marks enlargement of the liver and spleen without ascites; 
jaundice, with fever ; pain in the hepatic region ; and, subse- 
quently, malignant jaundice, with typhoid symptoms, rapid wast- 
ing, coma and convulsions. 

Acute yellow atrophy, which has many of the symptoms of 
the final stage of the biliary cirrhosis, is distinguished by its 
abrupt onset and rapid course, and is among the rarest of diseases 
in children. 

Prognosis. — The result is almost invariably unfavorable, and 
it is only under the most fortunate conditions that even a tem- 
porary improvement can be obtained. 

Treatment. — Before a diagnosis is established, and while the 



356 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

patient is merely suffering from ill-defined symptoms of bad 
health, with imperfect digestion, hygienic and therapeutic meas- 
ures are to be directed to the restoration and preservation of the 
general strength, and to correcting any disorder of the organic 
functions. 

When the hepatic affection declares itself, an alkaline or a 
purely tonic treatment may be adopted. Alkalies are indicated 
when the hepatic and gastro-intestinal symptoms are in excess of 
the wasting and general debility; tonics under opposite circum- 
stances. In the former case, the following prescription is 
useful : — 

R. Sodii Bicarb., gij. 

Tr. Nucis Vom., rr\xviij. 

Inf. Calumbae, q. s. ad fgiij. 

M. 
S. — Two teaspoonfuls three times daily, for a child of 
ten years. 

In the latter, Basham's mixture may be employed, or a com- 
bination of iron and quinine, as: — 

R. Quiniae Sulph., gr. xij. 

Tr. Ferri Chloridi, fgj. 

Syr. Zingib., fgj. 

Aquae, \. . . . q. s. ad f^iij. 

M. 

S. — Two teaspoonfuls three times daily. 

Both plans must be followed out steadily and continuously, to 
obtain any beneficial results. 

To relieve constipation, from two to four fluidounces of 
Hunyadi water should be taken every morning on an empty 
stomach. Diarrhoea can be controlled by sub-carbonate of 
bismuth, and hemorrhage by gallic acid or aromatic sulphuric 
acid. 

It is important to order a liberal diet — milk, eggs, meat and 
farinaceous foods in full proportion to the capacity of digestion. 
As in other diseases of the liver, the skin must be kept active by 



AFFECTIONS OF THE LIVER. 357 

daily warm baths, and chilling prevented by flannel under- 
clothing. 

If ascites be so great as to impede the action of the diaphragm, 
paracentesis must be resorted to at once. A fine trocar or one 
of Southey's tubes may be used.* The operation should be 
repeated so soon, and as often, as reaccumulation renders it neces- 
sary. When performed early enough, it sometimes has, as in 
adults, more than a merely palliative effect. 

7. SUPPURATIVE HEPATITIS. 

Abscess of the liver is an extremely uncommon disease 
in children. The only case that has ever come under my 
notice, presented the following clinical history: — 

George , set. 5 years, was first brought to the Dispensary 

of the Children's Hospital on April 27th, 1875, during the ser- 
vice of Dr. George S. Gerhard. Though residing in a malarious 
locality, and in a poor and filthily-kept house, he had always 
had good health up to one week previous to the above date, 
when he began to complain of pain in the region of the umbili- 
cus. Under appropriate treatment he passed several lumbricoid 
worms, and the pain disappeared. A week later, however, it 
returned, and as his bowels were constipated, his father adminis- 
tered a tablespoonful of castor-oil ; this produced a free evacua- 
tion, containing from twenty to thirty lumbrici, many being of 
large size. After this he seemed to be perfectly well until May 
9th, when the pain in the abdomen reappeared ; he now began 
to lose his appetite, and a swelling was noticed in the right 
hypochondriac region. 

When I saw him first, on May 15th, his general appearance 
was good ; his cheeks having a healthy color, and his body being 
sufficiently stout. His tongue was lightly coated, and his father 
stated that his appetite was poor, and that, though his bowels 
were moved daily, the passages were small. There was no heat 
of skin or jaundice, the pulse and respiratory movements were 

* See section on Ascites. 



358 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

normal in frequency ; he had no cough, and, on physical exami- 
nation, no pulmonary or cardiac affection could be detected. 
His abdomen was tympanitic, the whole of its upper third was 
tender to the touch, and in the upper part of the right hypo- 
chondrium there was an oval tumor, about as large as a turkey's 
egg, having its long diameter directed transversely, and project- 
ing at its most prominent part nearly an inch from the surface of 
the abdomen. The skin covering this tumor was somewhat 
cedematous, but was freely movable, and natural in color 
and temperature, while the tumor itself was hard, tender, com- 
pletely immovable, and the seat of neither fluctuation nor 
pulsation. It was surrounded by an area of induration, the 
boundary of which could not be accurately ascertained on 
account of the pain produced by palpation, though it appeared 
to extend from the costal border to the lower third of the right 
hypochondriac region, and from the median line of the abdo- 
men to the right side. 

The right hypochondrium was dull, except just below the 
margin of the ribs, where there was slight, probably transmitted, 
tympanitic resonance, detected only by deep percussion. The 
liver dulness began in the ordinary position atjpve, and, on 
light percussion, was continuous below with that in the hypo- 
chondriac region. The patient did not complain of pain except 
when the swelling was touched, or when the whole body was 
jarred, as in walking down stairs. On a level surface he was 
able to walk easily. No history of an injury could be obtained, 
but on careful questioning it was discovered that throughout the 
winter he had " coasted" a great deal on his sled, and always 
rode " belly-bumpers. " He was ordered to be kept quiet, and 
to have a liquid diet, with poultices over the abdomen, and a 
dose of castor-oil. 

May 1 6th. Had a large passage from the bowels, the evacua- 
tion being dark-colored and lumpy ; during the night was rest- 
less and feverish. 

May 17th. Tongue somewhat cleaner and abdomen less 
tympanitic. The tumor was more prominent ; there was deep- 



AFFECTIONS OF THE LIVER. 359 

seated fluctuation, and the skin covering the mass was less (Edem- 
atous, not so freely movable as before, and of a dusky-red hue. 
Patient walked with his body bent forward, as if a more upright 
posture was painful. Prescribed f3ss of tinct. cinchon. comp., 
three times daily, and an increased diet, at the same time direct- 
ing his parents not to allow him to get out of bed, and to apply 
warm poultices continuously to the belly. 

May 19th. Visited him at his home, and found him entirely 
free from fever; his tongue was clean, his appetite had returned, 
and his bowels had been opened ; the stool, which had been 
kept for inspection, was copious, well formed, and in every way 
natural. The induration around the tumor, or more properly 
the abscess, for such it now appeared to be, had extended so as 
to fill nearly all of the right hypochondrium, being almost five 
inches in transverse diameter. There was well-marked fluctua- 
tion, and the skin investing the abscess was tightly adherent over 
a space about four inches in circumference. The abdominal 
respiratory movements were restricted, and any effort at full 
inspiration caused pain. There was no sensation of throbbing 
in the abscess, and the patient seemed to be perfectly comfort- 
able as long as he remained quiet. The abdomen was moder- 
ately distended. 

May 22d. No change, except that the fluctuation was more 
superficial, and the integument adherent over a large surface. 
The former treatment was continued, and as the pulse was more 
frequent than before, and as he was pale and languid, a teaspoon- 
ful of brandy thrice daily and full diet were ordered. 

May 26th. Found him up and playing about as if nothing 
was the matter. Having him stripped and placed in bed, the 
following observations were made : Abscess more prominent 
than at last note, but more localized ; in its centre there is very 
superficial fluctuation, extending over an area an inch and a half 
in diameter and bounded by a firm margin. The skin covering 
this space is dark red in color, feels very thin, almost as if it 
could be broken by the pressure of the finger, and is somewhat 
hotter than the surrounding integument. About the abscess 



360 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

there is a mass of induration which does not project beyond the 
level of the rest of the abdomen, but which extends from the 
lower border of the ribs to the middle of the right lumbar 
region, and from the mid-line of the abdomen to the right side; 
its outline is semicircular, the edge being smooth and well 
defined, so much so that the fingers can be inserted beneath it. 
The skin is adherent over the whole mass, but most so imme- 
diately around the position of fluctuation. Both palpation 
and percussion indicate that it is connected with the right lobe 
of the liver. There is some pain excited by palpation, though 
this is much less than formerly. There is no jaundice. No 
change was made in the treatment. 

May 29th. The abscess was more circumscribed, being about 
the size of an English walnut, and the pus was still nearer to the 
surface. As it was impossible to keep the patient quiet, and 
fearing lest he might rupture the abscess in his play, aspiration 
was determined upon. Accordingly, a large aspirator needle 
was introduced to the depth of half an inch. About two drachms 
of thick, grumous pus, mixed with blood, escaped into the 
receiver, when the canula became plugged, and no more could 
be withdrawn.* A poultice was applied, and the patient ordered 
to remain in bed during the rest of the day. The operation was 
followed by no bad symptoms, and the next day he was up, 
amusing himself as before. There was, however, considerable 
discharge of thick pus from the opening left by the aspirator 
needle. 

June 1st. The wound made by the needle closed. Scarcely 
any fluctuation could be detected, and there was but little red- 
ness of the skin. On passing the finger over the position of the 
abscess a cup-shaped depression was felt, bordered by a well- 
defined edge of dense tissue. The induration was reduced ; its 
lower margin was still semicircular, and could be easily isolated, 



* A microscopical examination of a portion of this material revealed pus 
cells, compound granule cells, blood corpuscles, and numerous polygonal cells 
having well-defined nuclei and resembling liver cells. 



AFFECTIONS OF THE LIVER. 36 1 

while the upper margin, on the other hand, could not be dis- 
covered, as the mass extended under the ribs. There was hardly 
any pain on manipulation, and the boy's general condition was 
very good. 

June 5th. There were no signs of the abscess, except a small 
spot of dusky redness, and slight retraction and puckering of the 
skin at the point of puncture ; in this situation, also, the integu- 
ments were adherent to the parts below. The induration was 
diminishing, and its edge, which could still be distinctly felt, 
was approaching the right costal border. All treatment was sus- 
pended. 

On October 30th, the child was in excellent health. The 
skin, for a short distance about the seat of puncture, was some- 
what discolored and puckered, and was less freely movable than 
that of the remainder of the abdomen. Percussion and palpation 
showed that the right lobe of the liver was slightly contracted. 

In reviewing the preceding history, the question that naturally 
suggests itself is, whether the disease was hepatic abscess, or 
merely an abscess of the abflominal wall. In the early stage of 
the former affection, the general symptoms are similar to those 
observed in acute hepatitis ; jaundice being present only in 
exceptional instances, while the formation of pus gives rise to 
rigors, frequency of the pulse, night sweats and fever, the latter 
often resembling the pyrexia of quotidian or tertian intermittents. 
The almost entire absence of constitutional disturbance in this 
case, however, is no argument against the existence of hepatic 
abscess; as it is generally admitted that the symptoms are often 
very latent, and that in many instances no suspicion of an abscess 
has been entertained until its discovery by manual exploration, 
or by the discharge of pus in various directions, and sometimes 
even not until revealed by post-mortem examination. 

The local symptoms, on the contrary, were well marked ; thus 
there was localized, though extensive, enlargement of the right 
lobe of the liver, and toward the upper part of this enlargement 
there was an ill-defined, oblong tumor extending beyond the 
level of the abdomen. The skin covering this tumor was at first 



362 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

slightly oedematous, but perfectly movable and normal in color 
and temperature. From day to day, as ~ the tumor became more 
circumscribed and approached nearer the surface, the hepatic 
enlargement increased, and conjointly with the appearance of 
fluctuation the oedema disappeared, the skin became dusky-red 
in hue, hotter than the surrounding integument, and adherent. 
There was also tenderness on pressure; pain excited by deep 
inspiration or any jarring movement, and a peculiar bending 
forward of the body in walking. Again, after the opening of 
the abscess, all these symptoms subsided, and there was puckering 
of the skin and rapid reduction in the size of the liver ; its pro- 
jecting margin remaining semicircular, smooth, and well defined. 
Finally, there was slight contraction of the right lobe. 

There are two other points of importance, viz., the detection, 
by palpation, of a smooth edge of dense tissue bordering the area 
of fluctuation, which gave the impression that the fluid was con- 
tained in a cup-shaped cavity in a solid organ, and the micro- 
scopical characters of the pus which was removed. 

Now, all these symptoms are characteristic of an hepatic abscess, 
so situated on the convexity of the liver as to point toward the 
surface of the abdomen ; the adhesion of the integuments being, 
of course, due to local peritonitis. 

Abscesses of the abdominal wall, on the other hand, besides 
being superficial from the outset, have a different position, being 
usually seated in the rectus muscle or adjoining connective tissue, 
and in the neighborhood of the umbilicus; at the same time 
there is generally violent throbbing pain ; the redness and tume- 
faction of the skin are earlier and better developed, and the 
constitutional symptoms accompanying the formation of pus are 
more constantly observed than in abscess of the liver. 

The general management of circumscribed hepatitis, prior to 
the formation of pus — if the symptoms be such as to lead to a 
diagnosis at this time — simply requires careful regulation of the 
diet, rest, and attention to the various functions of the body, 
particularly that of the bowels ; for even if the existence of in- 
flammation be ascertained, it is hardly probable that anything 
can be done to prevent suppuration. 



AFFECTIONS OF THE LIVER. 363 

In relation to the propriety of evacuating hepatic abscesses, 
the bulk of authority is in favor of so doing, when they point 
externally so as to be detected by palpation, when firm adhesions 
have formed, and when the pus is near the surface. As to the 
method of evacuation, a free incision is perhaps preferable to 
puncture with an aspirator needle ; first, because the pus is often 
mingled with shreds of connective tissue and broken-down liver 
substance, liable to obstruct the needle and render it useless ; or, 
even if all the fluid be withdrawn, to remain and prolong the 
process of suppuration ; second, as the inelasticity of the walls of 
the cavity cannot prevent the entrance of air, it is much better 
to provide a free way of exit, than to have the air confined, as it 
would likely be in the event of the small opening made by the 
needle becoming closed. For the purposes of exploration, how- 
ever, the aspirator may be used with advantage. After being 
opened, the abscess is to be dressed in the ordinary manner, 
while strict rest should be enjoined, and tonic and supporting 
measures employed. Subsequently, nutritious diet and exercise 
in the open air, the latter adapted to the strength of the patient, 
are much more important than mere medication. 

Tuberculosis of the liver is sometimes associated with tuber- 
cular peritonitis, and is commonly encountered at the autopsies 
of children who have succumbed to acute general tuberculosis. 
In such cases the liver is anaemic, yellowish and small. Semi- 
transparent granules (miliary tubercles) are seen upon the capsule 
and detected by the microscope in the connective tissue that 
surrounds the branches of the portal vein ; there is, too, an in- 
terstitial hepatitis, with the formation of embryonal and fibrous 
tissue. There are no definite symptoms, and a diagnosis is hardly 
possible without post-mortem section. 

Hydatid Disease and Cancer are so infrequent in child- 
hood, and when they do occur present so nearly the symptoms 
of the same conditions in adults, that it is unnecessary to devote 
space to their consideration. 



CHAPTER V. 
AFFECTIONS OF THE PERITONEUM. 



i. PERITONITIS. 

Children, like adults, are subject to attacks of inflammation of 
the peritoneum. These may be primary or secondary in origin, 
acute or chronic in course, and general or local in distribution. 

The affection occurs at any age from birth to puberty, and 
there are indisputable evidences on record of its developing 
during the later months of intra-uterine life. The primary or 
essential form is almost uniformly acute and general. Secondary 
peritonitis, on the contrary, may be either general or local, the 
inflammation often beginning in a limited area and gradually 
extending over the whole surface. It is also more common than 
the primary variety, and, while often acute, more frequently 
runs a chronic course. 

Morbid Anatomy. — In acute general peritonitis, the blood 
vessels of the sub-serous tissue of the peritoneum are engorged 
with blood, and the membrane is reddened, either generally or 
in patches ; mottled by isolated spots of ecchymosis, and opaque 
and thickened. Serum, sometimes clear, sometimes mixed with 
pus and flakes of fibrin, fills the abdominal cavity; or, again, 
the effusion may be purulent ; in either case, it is most abundant 
in the pelvis and between the mesenteric folds. 

Acute local peritonitis occasions connective tissue hyperplasia, 
omental and intestinal adhesions, and, at times, localized sup- 
puration. 

Chronic general peritonitis gives rise to a sero-fibrinous exu- 
date ; this may be sufficiently abundant to appear as a thick 

3 6 4 



AFFECTIONS OF THE PERITONEUM. 365 

membrane, and in time may undergo fatty, caseous or calcareous 
degeneration. 

Chronic local peritonitis results in the formation of circum- 
scribed adhesions, membranous exudations of limited extent, and 
sacculated collections of pus. 

Etiology. — Foetal peritonitis is caused by syphilis or some 
specific infection of the mother. During the first few days of 
life it may be due to inflammation, suppuration or gangrene of 
the umbilicus; to congenital occlusion of the anus; or to in- 
fection from a mother ill with puerperal fever. Later in child- 
hood, primary peritonitis arises from blows upon, or other injuries 
to the abdomen, and from sudden chilling of the body after 
violent exercise ; a number of cases having been noted in which 
the attack could be traced to the act of lying to rest, after an 
exciting or fatiguing game, prone upon damp ground. The 
secondary form may result from the escape of faecal matter into 
the abdominal cavity through a perforation of the intestine — 
called perforative peritonitis. It may also occur during the course 
of one of the exanthemata, scarlatina especially — septic peri- 
tonitis. Finally, it may be occasioned by extension of inflam- 
mation from some one of the abdominal viscera, or from the 
pleura ; in the last instance there may be an element of sepsis. 

Chronic peritonitis sometimes follows an acute attack, but 
is most often an attendant of tuberculosis and presents the 
characters of chronicity from the outset. 

Symptoms. — In primary peritonitis, and in other cases of the 
acute general disease not due to perforation or sepsis, the attack 
begins with more or less rigor, abdominal pain and vomiting. 
The pain is stinging or lancinating in character, and is limited, 
at first, to one flank, to the supra-pubic region, or the neighbor- 
hood of the umbilicus, but soon becomes general ; it is increased 
by pressure or by any act calling the abdominal muscles into 
play, as deep breathing, sneezing, coughing and vomiting. The 
vomiting is frequent and very violent, producing so much distress 
and fatigue that after each effort the patient falls back on the 
pillow with pale, haggard, and sweat-bedewed face ; the material 



$66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

rejected consists, in the beginning, of partially digested food ; 
later, of bile-stained mucus. 

Fever quickly follows the shivering, and as soon as inflamma- 
tion is fully established, the axillary temperature may reach 
104 F., although the usual range is from 101 to 102 . With 
the pyrexia there is a frequent, small, wiry pulse, and the breath- 
ing assumes the superior costal type ; in some cases (where there 
is a large effusion) growing hurried and difficult. The child 
ceases to move his legs, or takes to bed early and lies immovably 
upon his back, with the knees drawn up. The face is pale and 
anxious, the nose sharp and the nostrils thin and expanded. The 
abdomen is distended and passive, so far as respiratory move- 
ments are concerned ; palpation yields a certain sense of re- 
sistance, sometimes develops fluctuation,* and always excites 
intense pain ; percussion elicits tympany over the upper anterior 
portion of the belly and dulness over the dependent parts, and 
on auscultation, friction sounds may be heard when there is a 
fibrinous exudation. 

The tongue is pointed, red at the tip and edges, and covered 
in the centre with a dry, moderately heavy, brown-white fur. 
There is anorexia and increased thirst. Constipation is the rule 
if the intestinal peritoneum be involved; then, too, there are 
frequent attacks of severe griping pain ; on the other hand, there 
may be diarrhoea, with watery evacuations, if the inflammation 
be attended by oedema of the sub-mucosa with transudation of 
serum into the bowel. 

The urine is high colored and somewhat reduced in quantity, 
and, while ordinarily passed with freedom, is retained when the 
serous coat of the bladder is involved in the inflammation. 

Sleep is disturbed and restless ; in infants there may be con- 
vulsions; in older children, delirium. 



* When fluctuation is indistinct, Duparcque recommends that the child be 
placed on one side for a few moments, so that the whole quantity of fluid may 
gravitate to the depending flank ; then quickly turned upon the back, when 
dulness and temporary fluctuation will be found at the site of accumulation. 



AFFECTIONS OF THE PERITONEUM. 367 

During the course of the attack, which usually extends over a 
period of seven days, the strength steadily fails; there is con- 
siderable loss of flesh, and the symptoms present at the onset 
continue unabated and unchanged. As death approaches vomit- 
ing usually stops, but the other symptoms become more and 
more grave. The patient lies in an apathetic condition, with 
sunken eyes and half-closed lids; his face is drawn and either 
pale or cyanosed ; the tongue is dry, brown and pointed ; there 
is marked tympanites and the pulse is extremely small and 
frequent. 

Occasionally this variety of acute peritonitis ends in recovery ; 
the exuded fluid being either reabsorbed or spontaneously 
evacuated through the umbilicus or abdominal wall.* In the 
first instance, the symptoms subside gradually ; in the second, 
rapidly ; though in both, the course is protracted ; the fistulous 
openings left after the discharge of pus rarely closing under four 
or five weeks. 

Perforative peritonitis requires separate description, since it 
has a set of symptoms entirely its own. It is the most common 
form of the disease in children, and in the majority of cases 
results from rupture of the vermiform appendix or caecum ; per- 
foration of typhus or tubercular ulcers being exceptional in this 
class of patients. 

The attack begins suddenly with intense pain in the abdomen, 
quickly followed by profound collapse. The face soon becomes 
pale and haggard ; the eyes are deeply sunken, and the hands 
and feet cold, though the body heat is increased; the rectal 
temperature ranging to 103 or 104 . Other features are great 
thirst, occasional vomiting, a dry, red and pointed tongue ; 
locked bowels ; a rapid, small, thready pulse ; thoracic respira- 
tion, often hurried and difficult, and suppression of urine. From 
the beginning the belly is greatly distended by gas escaping from 
the intestine ; the abdominal respiratory movements cease ; pal- 
pation is very painful, and percussion yields a uniformly drum- 

* M. Gauderon mentions ten such cases, eight of which recovered. 



368 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

like tympany that extends high up under the ribs, and completely 
masks the liver dulness. Death almost invariably takes place 
either on the third or fourth day of illness, and is usually pre- 
ceded by a few hours' freedom from suffering. 

While this is the ordinary course of perforative peritonitis, it 
happens sometimes that the shock is so great that the patient 
neither feels pain nor complains of tenderness when the abdomen 
is touched, arfd there is a general latency in the symptoms. 
Again, extravasation being limited by preformed adhesions, the 
inflammatory action is circumscribed, and the resulting abscess, 
by pointing and discharging through the abdominal wall or into 
the intestine, may either end in recovery, or in the production 
of a permanent faecal fistula. 

In septic peritonitis the symptoms are either inherently latent, 
or are masked by the collapse that follows ttee onset of anew in- 
flammation in a patient already debilitated by disease. There is 
usually rapid prostration, restlessness, and delirium, with a ten- 
dency to stupor ; a pale, anxious face ; swollen belly ; persistent 
watery diarrhoea ; a frequent, wiry pulse, and quick, costal 
breathing. Pain, tenderness, tension of the abdominal walls, 
dulness on percussion and fluctuation may be entirely absent. 
Without care, such attacks are readily overlooked. 

Should peritoneal inflammation become chronic the pain les- 
sens and is more paroxysmal in character ; the fever is remittent, 
with evening exacerbations; constipation alternates with diar- 
rhoea ; there is great emaciation, and death occurs from ex- 
haustion. However, on account of the usual tubercular origin, 
the symptoms of this form will be more appropriately studied 
under the head of " tubercular peritonitis." 

Local peritonitis is almost uniformly secondary ; that attending 
inflammation of the caecum and vermiform" appendix being the 
most common in children. 

Diagnosis. — An immovable dorsal decubitus ; a pale, hag- 
gard face ; a frequent wiry pulse : distention, pain and tenderness 
of the belly, and inactivity of the abdominal muscles in respira- 
tion, suffice to render the diagnosis of acute general peritonitis 



AFFECTIONS OF THE PERITONEUM. 369 

easy. Intense pain, sudden collapse and rapid and extreme 
meteorism characterize the perforative variety. 

In colic there is constipation and vomiting, with severe pain ; 
but between the paroyxsms there is no abdominal tenderness, and 
the pulse is never so rapid, small, and wiry, nor is there the fear 
of movement so noticeable in peritonitis. 

Rheumatism of the abdominal muscles is attended by tender- 
ness on pressure ; distressed facial expression ; dorsal decubitus 
with knees drawn up, and constipation, and thus simulates peri- 
tonitis; but the face is never haggard, there is no vomiting nor 
hiccough, nor distention of the belly, neither is tenderness ex- 
treme. The pulse is soft, compressible, and only moderately 
frequent; the temperatnre nearly normal, and the urine scanty, 
high-colored, acid and scalding. 

It is important to remember that constipation is the rule in 
peritonitis when the inflammation involves and paralyzes the 
muscular coat of the bowel ; diarrhoea, when it spreads through 
the muscular coat to the mucous membrane. 

The great difficulty in diagnosis is experienced with latent 
peritonitis, whether septic or due to other causes. Suspicion of 
its existence may be entertained when, in the course of any pre- 
disposing disease, the patient suddenly grows pale and haggard, 
and has a full belly, with a tendency on the part of the abdomi- 
nal muscles to become rigid on palpation. Restlessness, delirium 
and stupor, a change in the type of respiration and in the charac- 
ter of the pulse, all strengthen the suspicion. Under these cir- 
cumstances it is well to practice Duparcque's method for detect- 
ing the presence of fluid, and this, if successful, leaves no further 
doubt. 

In the words of Eustace Smith: "In cases of chronic em- 
pyema we should always be on the watch for the occurrence of 
peritonitis. If the child, after a period of improvement, cease 
all at once to gain ground, and begins to look pale and distressed, 
with an elevated temperature, a more or less distended belly, and 
a rapid, wiry pulse, we are justified in suspecting peritonitis, 

3 1 



370 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

although there be no tension, tenderness or other sign connected 
with the abdomen to give support to this opinion." 

Prognosis. — This must always be most grave. Perforative peri- 
tonitis is invariably fatal. The primary variety, when due to cold, 
exceptionally ends in recovery, and so, too, does the partial form. 

Treatment. — Absolute rest in bed and quiet surroundings are 
essential. Hot applications, in the form of light flax-seed poul- 
tices and of turpentine stupes, should be made to the surface of 
the belly ; or, if these fail to give relief, cloths wrung out of ice- 
water may be applied ; they must be frequently changed, to 
secure the constant action of cold. Leeching is sometimes of 
great service in subduing pain, but it is only to be employed with 
robust subjects and in an early stage of the attack. 

Of drugs, opium alone can be relied upon. It may be exhib- 
ited by the mouth, the rectum, or subcutaneously, and can safely 
be pushed to the point of producing drowsiness, with decided 
contraction of the pupils, provided ease from suffering be not 
attained before. For a child of six years, three drops of laudanum 
every two hours, by the mouth or rectum ; and, by hypodermic 
injection, one-eighteenth of a grain of sulphate of morphia, 
repeated as required, are the average commencing doses. 

Under no circumstances is a purge to be given. Should con- 
stipation be obstinate, and the indications urgent to unload the 
bowels, a simple enema may be employed. It is a good rule, 
however, to interfere as little as possible in this way. 

The patient's strength must be sustained by concentrated liquid 
food in small quantities and at short intervals. Three fluid- 
ounces of milk and two fluidounces of beef-tea, alternating, 
every two hours, with the occasional substitution of the yolk of 
a soft-boiled egg for one or the other, would be a proper diet for 
a child of six years ; stimulants are also necessary, and so soon 
as there is evidence of failing strength a teaspoonful of good 
whiskey must be added to each portion of milk. Bits of ice 
may be allowed from time to time to allay thirst and quiet the 
stomach. 



AFFECTIONS OF THE PERITONEUM. 37 1 

Should the inflammation subside, the opium is to be gradually 
withdrawn and its place supplied by sorbefacients and tonics ; at 
first mercury in alterative doses, or iodide of potassium, with 
quinine ; and, later, syrup of the iodide of iron. At the same 
time, the hot or cold application being removed, a weak mer- 
curial ointment should be rubbed into the skin of the belly once 
or twice daily ; for example : — 

R. Ung. Hydrargryi, 

Ung. Belladonnae, aa gij. 

Adipis, £iv. 

M. 

S. — Use locally as directed. 

A most important point is to make no change in the diet, 
except, perhaps, to increase gradually the quantity of liquid food, 
until convalescence be fully established. 

2. TUBERCULAR PERITONITIS. 

As a rule, peritonitis due to the presence of tubercle in the 
abdominal cavity runs a chronic course, and is associated with 
tuberculosis of some other organ of the body — of the brain or 
lungs, for instance ; less frequently it occurs as an isolated affec- 
tion. Acute tubercular peritonitis is not unknown ; it is detected 
with difficulty during life, and is invariably an element of general 
tuberculosis. The disease is quite common after the age of seven 
years, but is rare in earlier childhood and almost never met with 
in infancy. 

Morbid Anatomy. — At the autopsy of a child dead from 
tubercular peritonitis, the intestines will be found covered by a 
layer of yellow, greenish or gray lymph, varying in thickness, 
and either loose and soft in texture or tough. Lymph having the 
same characters also covers the parietal peritoneum, and extends 
between the intestinal coils, binding them, more or less firmly, 
together. The exudate contains caseous masses of variable size ; 
its meshes are filled with greenish-yellow, sometimes bloody, 
sero-purulent effusion, and a quantity of the same material is 



372 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

usually found in the dependent portions of the abdominal cavity. 
Removal of the layer of lymph discloses gray and yellow tuber- 
cles, studding the surface of the peritoneum, together with masses 
and broad plates of caseous consistence and tuberculous nature. 
The thickness and extent of the exudation, the number of granu- 
lations, and the size of the caseous masses increase with the 
chronicity of the attack. In acute cases the cheesy collections 
are absent ; the exudate is comparatively thin, soft and translu- 
cent, and the granulations, which vary in size from that of a 
pin's head to that of a pea, are scattered at intervals through its 
substance. 

The omentum is shriveled, hard and often firmly bound to 
the abdominal wall; the mesentery is firm and contracted; the 
mesenteric glands are enlarged and show evidences of cheesy or 
tubercular alteratfon ; tubercular ulceration of the bowels is 
common, and the liver may be increased in size from amyloid or 
fatty change, and in some instances is cirrhotic. Inspection of 
other organs of the body usually leads to the discovery of 
tubercle, though this is not uniformly the case. 

Tubercular peritonitis is not always general in distribution; 
when localized the inflammation and inflammatory products are 
usually to be observed in the neighborhood of the diaphragm. 

Etiology. — The factors leading to peritoneal tuberculosis are 
identical with those producing other tubercular affections. The 
age at which the disease is most prone to occur has already been 
mentioned. Male children seem to suffer more frequently than 
those of the opposite sex. 

Symptoms. — The onset is slow and insidious, and the physician 
is apt to have his attention diverted from the abdomen by more 
striking manifestations of tuberculosis of the lungs or other 
organs. Unless such features be present and precedent, there is 
but little evidence of failing health in the beginning, and the 
first symptom to attract notice is an abnormal prominence of the 
belly. The patient gradually grows dull and listless, looks ill, 
and, on account of abdominal tenderness and the pain produced 
by jarring, becomes slow and guarded in his movements. 



AFFECTIONS OF THE PERITONEUM. 373 

Often after the disease is fully developed the child " keeps 
about," but the face is drawn and wears an expression of anxiety 
and suffering ; the frame slowly wastes and the skin becomes dry 
and harsh and loses its healthy hue. Complaints are made of 
tenderness and griping pains in the abdomen, and the little 
sufferer takes very characteristic precautions to lessen his ills by 
steadying his belly with his hands in walking, and by moving 
down stairs backward so as to pass from step to step on his toes, 
to avoid jolting. The symptoms denoting disturbance in the 
functions of the gastro-intestinal tract are inconstant at this stage 
of the disease ; the tongue either shows little alteration or is 
lightly frosted or more pointed and red than natural ; nausea 
and vomiting may be entirely absent, and are never so persistent 
and severe as in simple peritonitis ; the appetite often remains 
unimpaired, and the bowels are alternately relaxed and confined. 
On the other hand the signs to be detected by abdominal explor- 
ation are very constant and characteristic. The belly is oval in 
shape and somewhat irregularly distended, the greatest enlarge- 
ment occupying the epigastric and umbilical regions; the natural 
folds and furrows are obliterated ; the superficial veins are promi- 
nent; and the integument has a smooth, shining appearance, as 
if smeared with oil. When the hand is applied to the surface, 
the recti muscles become tense, in an involuntary effort to pro- 
tect the tender parts beneath; some portions of the abdomen 
feel soft and flaccid ; in others, firm masses are perceptible to 
the touch; tenderness on pressure is universal, though most 
marked over the firm masses. Palpation also reveals fluctuation ; 
this is usually indistinct, though occasionally, when enlarged 
glands or cheesy masses exert pressure on the portal vein, there 
is a large collection of fluid in the peritoneal cavity, and the 
fluctuation wave is readily elicited and very distinct. The edge 
of the right lobe of the liver can often be felt extending half an 
inch or more beyond the right costal border. On percussion, 
tympany will be elicited over the flaccid portions of the abdomen ; 
dulness over the firm masses and flatness over the flanks — in the 



374 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

recumbent position — while, if the patient be rolled to one side, 
the note on the flank turned uppermost becomes tympanitic. 

The respiratory movements are somewhat increased in fre- 
quency and thoracic in type ; the pulse is quickened and feeble 
in proportion to the general weakness ; the axillary temperature 
ranges from g8° F. in the morning to ioi° in the evening; and 
there is dysuria with high-colored, but otherwise unaltered, urine. 
Sometimes, with a large collection of fluid in the peritoneum, 
there is oedema of the feet and legs; then, too, the urine may 
be slightly albuminous. 

In time the patient is forced to go to bed, where he lies on 
his back, or partially turned on one side, with his legs drawn 
up; this position is rigidly maintained, for every movement is 
painful. Now, the wasting is rapid ; the face wears a haggard 
expression ; the cheeks and temples are hollow, and the skin 
becomes inelastic and dotted with purpuric spots. The tongue 
is dry, heavily coated, or red and smooth ; the appetite fails and 
there is urgent thirst. The bowels are in one of two conditions: 
relaxed, with watery, offensive stools, containing flaky matter 
and small black clots of blood when there is tubercular ulcer- 
ation ; obstinately confined, when the intestines are pressed upon, 
or obstructed by adhesions. In the latter case the belly becomes 
greatly distended, and there are frequent attacks of severe colicky 
pain. Under other circumstances, however, the size of the belly 
may diminish, and then hard, tender lumps are felt in contact 
with the abdominal wall. The pulse is more frequent and feeble ; 
the evening temperature ranges as high as 103 and 104 , and 
night sweats are common. 

Death occurs after a lapse of time varying from several months 
to a year or more. 

The course of the disease is not uniformly progressive, being 
interrupted by remissions and exacerbations. During the former 
the tenderness and distention of the abdomen diminish, the 
appetite returns, nutrition improves, and false hopes arise of 
rapid recovery. 



AFFECTIONS OF THE PERITONEUM. 375 

Sometimes before death an abscess forms, and pus is discharged 
through the abdominal wall in the neighborhood of the um- 
bilicus; in other cases the intestines may be perforated from 
without, but this complication scarcely hastens the fatal termi- 
nation, for extravasation is limited by adhesions between the 
knuckles of the intestines. Such complications as tuberculosis 
of the lungs and cerebral meninges, however, certainly hasten 
death. 

Acute tubercular peritonitis always occurs as an element of 
disseminated tuberculosis, and presents the general features of 
that condition ; usually there are no local manifestations other 
than abdominal fulness and slight pain — symptoms sufficiently 
common in children to be altogether indefinite. The course of 
these acute attacks is measured in little more than a week. 

Diagnosis. — Ordinarily the formation of a correct opinion is 
not difficult. The distinctive features are the irregular disten- 
tion of the abdomen ; the smooth, shiny appearance of the in- 
vesting skin ; tenderness ; unequal resistance to the touch in 
different positions, and indistinct fluctuation, combined with 
alterations in the temperature ; impairment of nutrition ; an 
insidious onset ; a family record of tuberculosis or scrofula ; the 
presence of the tubercular diathesis, and the existence of symp- 
toms of tubercular deposit in some other organ of the body. In 
doubtful cases, where there is little distention or tenderness, and 
fluctuation is absent, it is well to try the effect of a sudden jar ; 
this may be done by directing the child to jump from a low 
chair to the floor. Free fluctuation is to be regarded as a point 
in the negative. 

Many children have prominent bellies and suffer severely from 
abdominal pain, both due to the accumulation of flatus in the 
intestines, the consequence of a chronic catarrh of the mucous 
lining. These patients, though pale and flabby, are but little 
wasted, and express in their faces no trace of severe illness ; they 
are lively in action ; their temperature is normal ; there is no 
tenderness or involuntary contraction of the recti muscles on 
palpation ; the abdominal distention disappears spontaneously at 



376 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

times, and subsides entirely when a non-farinaceous diet is or- 
dered. There can be no greater mistake than that of attributing 
every instance of abdominal distention to tuberculosis. 

As already stated, the diagnosis of the rare acute form is very 
difficult, and is often only made at the post-mortem table. 

Typhoid fever is the disease most likely to be confounded with 
it, but the absence of rash and splenic enlargement, and the dif- 
ference in the degree and course of the fever, should prevent 
error. 

Prognosis. — This must always be unfavorable. Recovery, 
though possible, is extremely rare. 

Treatment. — While little is to be expected from therapeutic 
measures, the physician's ambition will be to obtain a favorable 
result if he can. To accomplish this end it is necessary, first, to 
keep the child at perfect rest in bed ; and second, to select a diet 
that will meet the capacity for digestion, excluding as nearly as 
may be the farinaceous foods so prone to cause acidity and flatu- 
lence, with their attendant suffering. The following is a sample 
diet list for a patient of seven years : — 

For breakfast, at 7.30 a.m. — The yolk of a soft-boiled egg 9 a 
slice of well-toasted bread lightly buttered, and a tumblerful 
(fgviij) of warm milk. 

For luncheon, at 12 m. — The soft parts of a dozen oysters or 
a bit of fish, or a bowl (fSvj) of good beef-tea, with a biscuit. 

For dinner, at 3 p.m. — Two to four tablespoonfuls of minced 
mutton or chicken, one or two thin slices of stale buttered bread, 
eight tablespoonfuls of rice and milk or junket. 

For supper, at 7 p.m. — Two slices of milk-toast and a tumbler- 
ful of warm milk. 

Such a list can only be used in the earlier stages of the disease \ 
later, when the appetite fails, it is necessary to resort to liquid 
food, milk and meat broths, administered in small quantities at 
short intervals. 

Stimulants — and whiskey is the best — are required from the 
beginning, and must be given in increasing quantities as the 
strength fails. 



AFFECTIONS OF THE PERITONEUM. 377 

Of drugs, opium, quinine, and syrup of the iodide of iron 
with cod-liver oil, when the stomach will bear them, are the 
most useful. Opium must be given sufficiently freely to relieve 
pain, and quinine in doses large enough to maintain the flagging 
forces. Constipation is to be remedied only by simple enemata, 
while excessive diarrhoea may be checked by full doses of bis- 
muth combined with ipecacuanha and opium, as : — 

R . Pulv. Ipecacuanhse Comp., gr. xxiv. 

Bismuth. Sub-carb., • • 3J« 

Pulv. Aromat., gr. xij. 

M. et ft. chart. No. xij. 
S. — One powder every two or three hours for a child of 
seven years. 

A good formula for the same purpose is : — 

R. Ext. Haernatoxyli, gr. xxx. 

Tr. Opii Deod., TT^xxiv. 

Vin. Ipecacuanha, Tr^xxxvj. 

Mist. Cretae, q. s. ad fgiij. 

M. 
S. — Two teaspoonfuls every three hours. 

Externally, light flax-seed poultices are useful in relieving 
pain. Sometimes even the lightest poultice is uncomfortable, 
then the abdomen may be anointed once daily with — 

R. Ext. Belladonnae, gij. 

Glycerinae, f ^ vj. 

M. 

and covered with a thick layer of cotton batting. 

Should the quantity of fluid in the peritoneum be large, 
diuretics and diaphoretics are indicated ; if excessive, paracen- 
tesis is required. 

3. ASCITES. 

The collection of a quantity of transparent serum in the sack 
of the peritoneum is not of very common occurrence during 
childhood. The condition is, probably, always secondary, and 
must be regarded rather as a symptom than a disease proper; 

3 2 



378 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

it is of sufficient import to warrant a brief, separate considera- 
tion. 

Etiology. — Ascites is sometimes produced by simple or tu- 
bercular inflammation of the peritoneum ; more frequently it 
depends upon obstruction to the return of venous blood, due to 
diseases of the liver or heart ; to enlargement of the mesenteric 
glands, and, occasionally, to disease of the lungs ; again, it may 
be the result of a general hydraemic state of the blood, attend- 
ing affections of the kidneys and anaemia. It is occasionally 
impossible to decide upon the preexisting lesion. 

Symptoms. — In a well-developed case the abdomen is dis- 
tended and globular, the exact shape depending upon the posi- 
tion of the patient, being broader in the recumbent than in the 
erect posture, as, then, the fluid tends to spread and collect in 
the flanks. The integument is smooth and shining; the super- 
ficial veins are very distinct, and the normal depression at the 
umbilicus is either effaced or there is a projection at this point. 
There is a sense of fullness, with moderate resistance, but no 
tenderness on palpation ; and if a hand be placed on either side 
of the belly, and a sharp tap given with one of the fingers, a 
distinct impulse — fluctuation wave — is felt by the other hand ; 
this is not interrupted by pressure, made by an assistant, on the 
median line. While the child lies upon its back, percussion is 
tympanitic over the upper anterior parts of the belly, where the 
intestines float free, and dull elsewhere ; a change in position alters 
the relation of the areas of tympany and dullness, and the extent 
of the latter depends entirely upon the amount of fluid present. 
Pain is not a prominent symptom ; if present, it is paroxysmal, 
and has the griping character of the colic of intestinal indiges- 
tion. Such attacks are often attended or followed by moderate 
diarrhoea ; in the intervals the trowels may be confined. Should 
the effusion be large the mere weight of the fluid causes discom- 
fort ; then, too, respiration is embarrassed, even to the extent of 
orthopncea ; micturition is painful ; the urine is scanty, high- 
colored and albuminous, and there may be oedema of the geni- 
talia and legs, resulting solely from pressure. 



AFFECTIONS OF THE PERITONEUM. 379 

Cases having an obscure etiology furnish few additional fea- 
tures ; there are no constant or characteristic alterations of the 
tongue, appetite, appearance of the skin or temperature ; for 
these, with other rational symptoms, depend upon the determin- 
ing disease. 

When due to inflammation of the peritoneum, the amount of 
effusion is small ; the abdomen is tense and tender ; the tempera- 
ture is usually elevated, and the general symptoms of acute or 
chronic peritonitis are more or less marked. 

In hepatic disease, especially cirrhosis, the effusion is great ; 
the superficial abdominal veins are very prominent ; the hemor- 
rhoidal veins are distended ; the spleen is often enlarged ; the 
digestive functions are impaired, and the general integument has 
a sallow hue or is decidedly jaundiced. 

Cardiac disease causes anasarca and hydrothorax as well as 
ascites, and these conditions are apt to be associated ; the face is 
livid ; the lips and finger tips blue ; the jugular veins are dis- 
tended and pulsating ; there is dyspnoea, and a scanty, albu- 
minous urine, with the physical signs of heart lesion. 

Diagnosis. — There is little difficulty in detecting ascites, un- 
less the effusion be so small that it sinks away into the pelvis or 
between the folds of the intestine beyond the reach of the ex- 
aminer's hand. Under these circumstances it is well to try Du- 
pircque's method (see page 366) of increasing the distinctness of 
fluctuation, or to put in practice another plan for the same pur- 
pose, namely, placing the patient on the hands and knees so that 
the fluid may gravitate to the most dependent portion of the 
abdomen— now the neighborhood of the umbilicus — and come 
within the range of palpation. 

A large belly, produced by flatulent distention of the intes- 
tines, may yield indistinct fluctuation, the palpation stroke being 
transmitted through the bowels ; but the imperfect wave is readily 
interrupted by pressure in the median line, and the results of 
percussion are quite different from those obtained in ascites. 

The collection of a large quantity of fluid in the pelvis of one 



380 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

or other kidney — hydronephrosis — is attended by abdominal 
distention, fluctuation, and percussion dulness. The enlarge- 
ment, however, is more noticeable on the side of the affected 
kidney : here, also, there is more resistance and greater dullness, 
the opposite flank being often tympanitic ; changes of position 
have little effect in altering the percussion sounds, the umbilicus 
rarely protrudes, a kidney-shaped outline can often be detected, 
and tapping liberates a liquid charged with urea. 

The Prognosis depends chiefly upon the nature of the origin- 
ating disease. When this cannot be discovered, the forecast 
must be based upon the general strength and nutrition, the con- 
dition of the skin, the temperature, and the character of the 
urine. If the strength be moderately preserved, the appetite and 
digestion fairly good, the skin natural in texture and color, the 
temperature normal, and the urine free and non-albuminous, the 
prognosis for an ultimate recovery is good, irrespective of the 
amount of effusion. 

Treatment. — This must, in the main, be regulated by a con- 
sideration of the primary disease. Cases of obscure origin, as 
well as those depending upon anaemia or disease of the liver, are 
much benefited by full doses of iron. The tincture of the 
chloride of iron or the dried sulphate are, perhaps, the best 
preparations to use, and their effect is increased by the addition 
of quinine. The following is a serviceable formula : — 

R. Ferri Sulph. Exsiccat., ... gr. xxiv (to be increased to gj). 

Quiniae Sulph. , gr. xij. 

Acid. Sulphurici dil., .... rr^xij. 
Syrupi, f|j. 

Aqua? Menth. Pip., . . q. s. ad f g iij. 
M. 

S. — Two teaspoonfuls three times daily, taken diluted and 
after eating, for a child of six years. 

Diuretics can be employed at the same time, if there be no 
kidney complication, for example : — 



AFFECTIONS OF THE PERITONEUM. 38 1 

R. Potassii Acetatis, . ^ij. 

Spt. Juniperis Comp., f^ss. 

Spt. ^Etheris Nitrosi, f 3 vj. 

Syrupi, fgij. 

Aquce, q. s. ad f% vj. 

M. 
S. — Two teaspoonfuls every three hours. 

A combination of acetate of potassium, squill and digitalis is 
often useful. 

Should this class of remedies fail, much may be accomplished 
by a properly regulated course of purgatives. For this purpose, 
thirty grains of compound licorice powder, or ten grains of com- 
pound jalap powder, may be given from two to three times daily. 
Sometimes it is advisable to begin this treatment by two grains 
of calomel, administered at bedtime, and followed next morning 
by a teaspoonful of magnesia. 

It is always important to keep the skin active by a daily warm 
bath, and to maintain an equal surface temperature by woolen 
underclothing. 

The diet should contain as little fluid as possible ; thus the 
child may eat — 

For Breakfast. — A saucer of oatmeal porridge or cracked wheat 
with cream ; a soft-boiled egg ; two slices of stale bread or toast 
with butter ; a teacupful (four fluidounces) of milk. 

For Dinner. — A bit of roast chicken, or tenderloin of beef- 
steak, or roast beef or mutton ; mashed potatoes with gravy, or 
spinach or cauliflower ; two or three slices of stale bread ; rice 
pudding or junket and a glass of filtered water. 

For Supper. — A poached egg on toast, or a bowl of cream 
toast and a cup of milk. 

Between meals, some water must be taken to relieve thirst, but 
the less the better. 

When the fluid does not diminish after a thorough trial of 
ordinary remedies, the peritoneal cavity must be tapped. It is 
best to make the puncture with a very fine canula ; the instru- 
ment having been inserted is left in position ; a rubber tube is 



382 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 

attached, and the fluid allowed to drain away slowly for some 
eight or ten hours, constant and equal pressure being maintained 
in the meanwhile by a broad bandage. After the canula is re- 
moved, the abdomen must either be strapped or carefully band- 
aged. The effusion is never entirely removed in this way, but 
enough is taken to relieve pressure and allow absorption to go on. 
This method of operation causes so little pain, that, if necessary, 
but slight objection is offered to its repetition ; in very timid 
subjects, though, it is well to lessen the sensibility of the skin by 
the momentary application of ice and salt to the point selected 
for puncture. Paracentesis is often a remedial agent of much 
value ; though in some cases it is merely palliative. 



INDEX. 



Abdomen, barrel-shaped, 49 
distention of, 48 
examination of, 47 
scaphoid, 50 
tenderness of, 50 
Abdominal respiration, 39 
Abnormal dentition, 149 
Abscess, mammary, 67 

retropharyngeal, 197 
Absorption of fat, 47 
Accelerated breathing, 40 
Acute gastric catarrh, 199 

anatomical lesion of, 206 
symptoms of, 200 
diagnosis of, 201 
prognosis of, 201 
treatment of, 201 
intestinal catarrh, 227 

etiology of, 228 
symptoms of, 229 
diagnosis of, 230 
prognosis of, 230 
treatment of, 231 
Acute pleuritis, 27 
Affections of the liver, 337 

of the mouth and throat, 1 24 
of the peritoneum, 364 
of the stomach and intestines, 
199 > 
Air insufflation of, 309 
A\dd nasi, dilatation of, 21 
Alantoin, 33 
Albumin, 35 
Ammoniacal breath, 31 
Amyloid liver, 347 

morbid anatomy of, 347 
etiology of, 348 
symptoms of, 348 



Amyloid liver, diagnosis of, 349 
prognosis of, 349 
treatment of, 349 
Anaemia, 44, 1 21-123 
Analysis of breast-milk, y^ 
Anatomical lesion of acute gastric 
catarrh, 200 

of aphthous stomatitis, 

126 
of catarrhal stomatitis, 

124 
of simple pharyngitis, 

183 

of ulcerative stomatitis, 

131 

Anterior fontanelle, 46 
Antiseptics in entero-colitis, 257 
Apex beat in pleuritis, 52 
Apparatus for gavage, 113 

for hand feeding, 96 
Aphthous stomatitis, 126 

anatomical lesions of, 126 
etiology of, 1 26 
symptoms of, 127 
diagnosis of, 128 
treatment of, 128 
Arrowroot water, 232 
Artificial feeding, 71 
Ascaris lumbricoides, 312 
egg of, 313 
symptoms of, 319 
treatment of, 321 
Ascites, 377 

etiology of, 378 
symptoms of, 378 
diagnosis of, 379 
prognosis of, 380 
treatment of, 380 
Aspirating hepatic abscess, 363 
Asses' milk, 73 



383 



3^4 



INDEX. 



Asthma, 41 
Astringent bath, 1 04 
Atrophic cirrhosis, 352 
Atrophy, simple, 279 
Attendant, questioning the, 18 
Auscultation of the chest, 52 
Auvard's hatching cradle, 1 1 1 

B. 

Bandage, abdominal, 105 
Barley water, 80 
Barrel-shaped abdomen, 49 

chest, 51 
Basham's mixture, modified, 350 
Bath, astringent, 104 

bran, 104 

cold, 103 

cooled, 103 

hot, 103 

mercurial, 104 

mustard, 104 

nitro muriatic acid, 104 

salt water, 104 



sod; 



104 



Bathing, 102 

mode of, 102 
Bed clothes, 108 
Beef juice, raw, 92 

tea, 84 
Bethlehem oatmeal, in constipation, 

276 
Bicarbonate of sodium, 80, 87, 88 
Blennorrhoea, 178 
Boiled milk, 85 
Boracic acid, 68 
Bothriocephalus latus, 311 
Bottle, graduated nursing, 95 
Bottle tip, 96 
Bran bath, 104 

Brandy and egg mixture in intussuscep- 
tion, 308 
Breast-feeding, 60 

proper, number per day, 62 

milk, analysis of, 73 
spec. grav. of, 72 
Breath, the, 29 

fetor of, 3 1 

ill smelling, 29 
Breathing, different forms of, 41 

puerile, 52 
Bridge of nose, broadness of, 23 



Bright's disease, 34 
Brinton's theory of faecal 

303 
Bronchitis during dentition, 179 
Broth, veal, 92 

veal, with barley water, 208 
Brows, contraction of, 22 



Calculi, intestinal, 288 

Cancer of the liver, 363 

Cardiac disease, 56 

Caseous degeneration and tuberculosis 

of the mesenteric glands, 329 
Casts in the urine, 36 
Catarrh, acute intestinal, 227 

chronic gastro-intestinal, 213 
of the bladder, 36 
Catarrhal stomatitis, 124 

anatomical lesions of, 124 
etiology of, 124 
symptoms of, 125 
treatment of, 125 
Causes of ill smelling breath, 29 
Cereal foods, 77 
Cerebral disease, 24 
Cestodes, 311 
Cheese poison in milk, 99 
Chest, examination of, 50 
inspection of, 51 
barrel-shaped, 51 
auscultation of, 52 
palpation of, 54 
percussion of, 55 
Cheyne-Stoke's respiration, 41 
Child, inspecting the, 20 

position of, during feeding, 97 
Children, general management of, 60 
Childhood, 100 

Chlorate of potassium, 134, 135 
Cholera infantum, 258 

morbid anatomy of, 258 
etiology of, 259 
symptoms of, 2^9 
diagnosis of, 261 
prognosis of, 262 
treatment of, 262 
Chorea, 122, 182 
Chronic diarrhoea, 235 

enlargement of tonsils, 24, 194 
entero-colitis, 235 



INDEX. 



3S5 



Chronic entero colitis, morbid anatomy 
of, 235 
etiology of, 235 
symptoms of, 236 
diagnosis of, 240 
prognosis of, 240 
treatment of, 241 
gastric catarrh, 202 

morbid anatomy of, 203 
etiology of, 203 
symptoms of, 204 
diagnosis of, 206 
prognosis of, 206 
treatment of, 207 
gastro-intestinal catarrh, 213 
hydrocephalus, 46 
intussusception, 304 
lung disease, 26 
peritonitis, 364 
Cirrhosis of the liver, 352 

morbid anatomy of, 352 
etiology of, 353 
symptoms of, 354 
diagnosis of, 355 
prognosis of, 355 
treatment of, 355 
Clinical investigation of disease, 17 

thermometer, 43 
Clothing, 105 

change of, 105 
Clotting, to prevent, 79 
Clubbing of the ringer tips, 26 
Cold bath, 103 
Colic, 270 

etiology of, 270 
symptoms of, 270 
treatment of, 271 
Collapse, 260, 263, 302 
Colon, 299 
Condensed milk, 75-85 

reared children, 76 
Congestion of the liver, 343 

morbid anatomy of, 343 
etiology of, 343 
symptoms of, 343 
diagnosis of, 344 
prognosis of, 344 
treatment of, 345 
Conjunctival blennorrhcea, 151 

during primaty denti- 
tion, 178 



Constipation, (see Habitual Constipa- 
tion, 273) 
Convulsions caused by teething, 16 1 

in chronic entero-colitis, 238 
Cooled bath, 103 
Cough, varieties of, 28 

stomach, 227 
Cows' milk, analysis of, 74 
spec. grav. of, 74 
sound, 98 
Cream, whey and barley water mix- 
ture, 207 
Crib, the, 108 
Croup, 59 
Cyanosis, 112 

Crying, different characters of, 27 
Crusta lactea, 156 
Cysticercus cellulosse, 316 
Cystitis, tubercular, 361 

D. 

Day nursery, 107 

Decubitus, 23 

Defecation, frequency of, 32 

Deformity of sternum caused by hy- 
pertrophy of tonsils, 195 

Dental paralysis, 162 

Dentition, 148 

delayed, 150 
difficult, 150 
irregular, 150 

Dermatitis, 155 

Development, 45 

Diabetes, 34 

Diachylon ointment, 159 

Diagnosis of acute gastric catarrh, 201 
of acute intestinal catarrh, 230 
of amyloid liver, 349 
of aphthous stomatitis, 128 
of ascites, 379 
of cholera infantum, 261 
of chronic entero-colitis, 240 
of chronic gastric catarrh, 206 
of cirrhosis of the liver, 335 
of congestion of the liver, 344 
of dysentery, 265 
of entero colitis, 252 
of fatty infiltration of the liver, 

of follicular tonsillitis, 189 



3 86 



INDEX, 



Diagnosis of habitual constipation, 274 
of habitual indigestion, 217 
of intussusception, 305 
of jaundice, 339 
of mucous disease, 220 
of noma, 139 
of peritonitis, 368 
of simple atrophy, 284 
of simple pharyngitis, 184 
of suppurative hepatitis, 362 
of suppurative tonsillitis, 192 
of syphilitic hepatitis, 351 
of tabes mesenterica, 332 
of thrush, 145 
of tubercular peritonitis, 375 
of typhlitis, 291 
of worms, 319 

Diagram showing eruption of milk 
teeth, 148 
showing method of lancing gums, 

163 

showing relation between the 
permanent and temporary 
teeth, 170 
Diarrhoea, chronic, 235 

during 2d dentition, 177 
Diathesis, tuberculous, 22 
Diet during 2d dentition, 175 
during the first week, 81 
during the sixth month, 82 
for 8th and 9th months, 8^ 
for 7th month, 82 
for six weeks, 84 
for tenth month, 65 
for 10th and nth months, 84 
from 18 months to 2)4 years, 93 
from 2d to the 6th week, 81 
from 6th week to the end of 2d 

month, 82 
from 3d to the 6th month, 82 



from 



£ years up, 101 



from 1 2th to the 1 8th month, 93 

in amyloid liver, 349 

in aphthous stomatitis. 129 

in ascites, 381 

in acute intestinal catarrh, 232 

in chronic entero- colitis, 242,243 

in cirrhosis of the liver, 356 

in colic, 271 

in congestion of the liver, 345 

in constipation, 276 



Diet in dysentery, 266 

in entero-colitis, 255 

in intussusception, 308 

in mucous disease, 221 

in peritonitis, 370 

in simple pharyngitis, 185 

in suppurative hepatitis, 362 

in tabes mesenterica, 335 

in tapeworm, 324 

in tubercular peritonitis, 376 

in typhlitis, 293, 294 

up to 3^ years, 100 
Difficult dentition, 150 

complications during, 161 
local affections of, 150 
sympathetic effects of, 151 
Diphtheria, urine in, 37 
Disease, features of, 20 

investigation of, 17 

of the digestive organs, 124 
Disorders of the digestive system 

during 2d dentition, 176 
Distention of abdomen, 48 

of bladder, 50 
Drinking, mode of, 26 
Dysentery, 264 

morbid anatomy of, 264 

etiology of, 264 

symptoms of, 264 

diagnosis of, 265 

prognosis of, 265 

treatment of, 265 
Dyspnoea, expiratory, 41 

inspiratory, 41 

E. 

Ear-ache, 24, 27 

Ears, nerve supply of, 168 

Eating between meals, 101 

Eczema during primary dentition, 154 

during second dentition, 178 

of the scalp, 156 

treatment of, 157 
Em 1 eu rage, 116 
Egg of ascaris lumbricoides, 313 

of oxyuris vermicularis, 312 

of tricocephalus dispar, 314 
Electricity in paralysis, 1 21 
Electro-cautery, 196 
Emphysema, 31, 51 



INDEX. 



387 



En chien de fusil, 24 
Enemata in enterocolitis, 256 

purgative, 274 
Entero -colitis (summer diarrhoea), 248 
morbid anatomy of, 248 
etiology of, 249 
symptoms of, 250 
diagnosis of, 252 
prognosis of, 253 
treatment of, 253 
chronic, 235 
Epidemic cholera, 262 
Eruption of milk teeth, 57 

of permanent teeth, order of, 169 
of permanent teeth, 164 
of temporary teeth, 148 
Etiology of acute intestinal catarrh, 
228 
of amyloid liver, 348 
of aphthous stomatitis, 126 
of ascites, 378 
of catarrhal stomatitis, 124 
of cholera infantum, 259 
of chronic entero-colitis, 235 
of chronic gastric catarrh, 203 
of cirrhosis of the liver, 353 
of colic, 270 

of congestion of the liver, 343 
of dysentery, 264 
of entero-colitis, 249 
of fatty degeneration of the liver, 

347 
of fatty infiltration of the liver, 

346 
of follicular tonsillitis, 187 
of gangrenous stomatitis, 136 
of habitual constipation, 273 
of habitual indigestion, 213 
of hypertrophy of the tonsils, 194 
of intussusception, 300 
of jaundice, 338 
of mucous disease, 217 
of peritonitis, 365 
of simple atrophy, 279 
of simple pharyngitis, 183 
of tabes mesenterica, 330 
of thrush, 142 

of tubercular peritonitis, 372 
of tubercular ulceration of the 

intestines, 268 
of typhlitis, 289 
of ulcerative stomatitis, 131 



Evacuations, fecal, 31 
Examination, physical, 39 
Exercise, 108 
Exhaustion, 299 
Expiratory respiration, 41 
Explanation of Plate 1, 165 
Eyelids, incomplete closure of, 21 

lividity of, 25 

puffin ess of, 22 

twitching of, 21 
Eyes, nerve supply of, 167 
Eye teeth, 151 



Face, the, 21 

the change of features in disease, 
21 
Faecal abscess, 287 
accumulation, 49 
evacuations, 31 
tumor, 31 
Faradism, 122 
Farinaceous food, 76 
Fatty degeneration of the liver, 347 
liver, 346 

infiltration of the liver, morbid 
anatomy of, 346 
of the liver, symptoms 

of, 346 
of the liver, etiology of, 

346 
of the liver, prognosis 

of, 346 
of the liver, diagnosis 
of, 346 
Fauces, the, 58 
Febrile diarrhoea, 248 
Features of disease, 20 
Feeding, 60 

apparatus, care of, 97 
artificial, 71 
breast, 60 
by a wet nurse, 69 
general rules for, 79 
intervals of, 64 
mistake of constant, 63 
Fever, temperature in, 44 
Feverish breath, 30 
Filtered water, 10 1 
Finger-nails, blueness of, 26 
deformity of, 26 



3 8S 



INDEX. 



Fissure of nipple, 67 

treatment for, 68 
Flour ball, S3 
Follicular tonsillitis, 187 
etiology of, 187 
symptoms of, 187 
diagnosis of, 187 
prognosis of, 188 
treatment of, 189 
Fontanelle, 46 

bulging of, 46 
Fcod, farinaceous, 76 
Horlick's, 81 
Mellins, 81 
preparation of, 97 
quantity per diem, 77 
Forced enema in intussusception, 309 
Fraenum linguae, ulceration of, 150 
Friction, 1 17 

Formula for acute gastric catarrh, 
201 
for an alkali in jaundice, 339 
for catarrhal stomatitis, 126 
for chronic gastric catarrh, 210 
for congestion of the liver, 345 
for convulsions, 162 
for enlarged glands during 2d 

dentition, 178 
for entero- colitis, 257 
for jaundice, 342 
for painting about loose teeth, 172 
for peritonitis, 371 
for second dentition, 175 
for softening the gums, 172 
for tubercular ulceration of the 

intestines, 269 
for urticaria, 154 
for vomiting, 153 
Formulae for acute intestinal catarrh, 

233. 2 34 
for amyloid liver, 350 
for aphthous stomatitis, 130 
for ascaris lumbricoides, 322, 323 
for ascites, 380, 381 
for cholera infantum, 263 
for chronic entero- colitis, 244, 245 
for cirrhosis of the liver, 356 
for colic, 272 
for constipation, 277 
for dysentery, 266, 267 
for eczema, 158, 159, 160 
for follicular tonsillitis, 189, 190 



Formulae for hypertrophy of the ton- 
sils, 195, 196 
for intussusception, 307 
for laxative, 157 
for mucous disease, 224, 225, 226, 

227 
for oxyuris vermicularis, 321 
for simple pharyngitis, 185, 186 
for suppurative tonsillitis, 193 
for syphilitic hepatitis, 352 
for tabes mesenterica, 336 
for tapeworm, 324, 325, 326 
for thrush, 147 
for tubercular peritonitis, 377 
for typhlitis, 293, 294 
for ulcerative stomatitis, 134 

Furrows, facial, 22 



Gangrenous stomatitis, 136 

etiology of, 136 

symptoms of, 136 

treatment of, 137 
Gastric catarrh, acute, 199 (see Acute 
Gas. Cat.) 

chronic (see Chron. Gas. Cat.) 
Gastro-intestinal catarrh, 260 
Gastro-malacia, 212 
Gavage, 113 

de renfort, 1 14 
Gelatine, 80 
Genal furrows, 22 
General development, 45 
Gluten flour, 324 
Glycerine suppositories in constipation , 

276 
Goats' milk, 73 
Gradual weaning, 64 
Graduated nursing bottle, 95 
Growing pains, 123 
Growth, 45 
Gums, condition of during dentition, 

149 
"Gun-hammer" decubitus, 284 



H 



Habitual constipation, 273 
etiology of, 273 
symptoms of, 274 
diagnosis of, 274 



INDEX. 



389 



Habitual constipation, prognosis of, 
274 

treatment of, 274 
indigestion, 213 

etiology of, 213 

symptoms of, 215 

diagnosis of, 217 

prognosis of, 217 

treatment of, 217 
Halitosis, 29 
Hand-feeding, success in, 96 

to insure success in, 72 
Hands, movement of, 24 
Hard palate, 58 
Hatching cradle, 109 
Headache during second dentition, 

179 
Head, shape of, 23 
Heavy breath, 30 
Hebra's diachylon ointment, 159 
Hemorrhage, renal, 35 
Hepatitis suppurative, 357 

syphilitic, 351 
Herpes of the lips during second den- 
tition, 178 
Hip-joint disease, 46 
Hob-nailed liver, 352 
Horlick's food, 81 
Hot bath, 103 

Hydrocephalus, spurious, 206 
Human milk, substitute for, 73. 
Humanized milk, analysis of, 88 
Hunger, 27 

Hydatid disease of the liver, 363 
Hydrencephalic cry, 27 
Hydrocephalus, 46 
Hydronephrosis, 36 
Hypertrophic cirrhosis, 353, 
Hypertrophy of the tonsils, 194 

etiology of, 194 

symptoms of, 194 

treatment of, 195 
Hypostatic pneumonia in chronic en- 
tero-colitis, 238 



Icterus, 337 

neonatorum, 338 
in older children, 
treatment of, 342 



341 



Idiopathic form of acute gastric ca- 
tarrh, 199 

Ileo-caecal intussusception, 305 

Immature infants, management of, 109 

Incontinence, 36 

Incubator, 109. 

Incubators, description of, ill 

Indican, 34, 37 

Indigestion, 200 

Infants' food, type of, 72 
foods, 77 

Inflammation of the colon and rectum 
(see Dysentery), 264 

Injections, medicated, 320 

Inspection of chest, 51 
of child, 20 

Inspiratory respiration, 41 

Insufflation of air in intussusception, 

Intertrigo in simple atrophy, 283 
Intestinal concretions, 288 

worms, 311 
Intestines, nerve supply of, 166 
Intussusception, 296 

varieties of, 296 

morbid anatomy of, 297 

without symptoms, 297 

with symptoms, 297 

results of, 298. 

strangulation in, 298 

etiology of, 300 

symptoms of, 301 

diagnosis of, 305 

prognosis of, 306 

treatment of, 306 

reduction of, 309 
Invagination, 306 
Investigation of disease, 17 
Inward spasms, 283 

J. 

Jadelot's lines, 22 
Jaundice, 337 

etiology of, 338 

grade of seventy, 338 

diagnosis of, 338 

due to congenital malformation 
of the bile ducts, 339 

treatment of, 339 
Junket, 65 



39° 



INDEX. 



K. 

Kidney, sarcoma of, 36 
Kidneys, amyloid degeneration of, 38 
lesions of, 29 



Labial furrows, 22 

Lactation, 66 

Lactometer, 74 

Lancing the gums, 1 63 

Laparotomy in intussusception, 309 

Laryngeal stenosis, 41 

Larynx, nerve supply of, 168 

Lavage, 114 

Laxative confection, 279 

Leeds' analysis of breast milk, 73 

Leucorrhcea, 318 

Lids, incomplete closure of, 21 

Lime, saccharated solution of, 80 

water, 80 
Lines of Jadelot, 22 
Lips, herpes of, 178 

puffing of, 5 1 
Lithsemia, 36 
Lithuria, 35 
Liver, abscess of, 357 

affections of, 337 

amyloid, 347 

cancer of, 363 

cirrhosis of, 352 

congestion of, 343 

fatty degeneration of, 347 

hydatid disease of, 363 

fatty infiltration of, 346 

syphilitic inflammation of, 351 

tuberculosis of, 363 
Lividity of eyelids, 25 
Local treatment for simple pharyn- 
gitis, 186 
Loss of taste during second dentition, 

172 
Lungs, nerve supply of, 167 

M. 

Malarial fever, 37 
Mammary abscess, 67 
Management of weak and immature 
infant, 109 



Marasmus, 47, 305 
Massage, 1 16 

a frictions, 117 

effects of, 117 

in chorea, 122 

in chronic gastro-intestinal ca- 
tarrh, 119 

in colic, 120 

in constipation, 120 

in general debility and anaemia, 
121 

in infantile paralysis, 121 

in pleurisy, 123 

in pseudo-hypertrophic paralysis, 
123 
Masturbation, 35 
Maxillary bones, necrosis of, 31 
Meckel's ganglion, 166 
Meigs' food, 85 
Mellin's food, 81 
Membranous croup, urine in, 37 
Menstruation in nursing woman, 68 
Mercurial bath, 104 
Method of gavage, 113 

of giving suck, 62 
Microscopic examination in thrush, 

Micturition, painful, ^3 
Milk, asses', 73 
boiled, 85 
care of, 98 
condensed, 75 
cows', analysis of, 74 
goats', 73 

mixture for chronic gaslric ca- 
tarrh, 208 
mode of drinking, 26 
peptonized, 86 
poisoning, 100 
scanty secretion of, 67 
secretion of, 61 
sterilized, SS 
teeth, 57 

teeth, the eruption of, 148 
transportation of, 98 
Morbid anatomy of amyloid liver, 347 
of cholera infantum, 258 
of chronic entero coiiti>, 235 
of chronic gastric catarrh, 

203 
of cirrhosis of the liver, 352 



INDEX. 



391 



Morbid anatomy of congestion of the 
liver, 343 
of dysentery, 264 
of entero-colitis, 248 
of fatty degeneration of the 

liver, 347 
of fatty infiltration of the 

liver, 346 
of intussusception, 297 
of peritonitis, 364 
of simple atrophy, 279 
of suppurative tonsillitis, 190 
of syphilitic hepatitis, 351 
of tabes mesenterica, 329 
of thrush, 142 

of tubercular peritonitis, 371 
of tubercular ulceration of 

the intestines, 268 
of typhlitis, 287 
Morbus cceruleus, 25 
Mortality from laparotomy in intus 

susception, 310 
Motor paralysis, 25 
Mouth and fauces, examination of, 57 
inspection of, during second denti- 
tion, 177 
soreness of, 26 
Mucous disease, 217 

etiology of, 217 
symptoms of, 218 
diagnosis of, 220 
prognosis of, 220 
diet for, 221 
treatment of, 220 
Mustard bath, 104 



N. 

Nails, deformity of, 26 
Naphthalin in entero-colitis, 257 
Nasal catarrh during second denti- 
tion, 178 
treatment of, 179 
Nausea, 39 
Necrosis, 135 
Nematodes, 31 1 
Nephritis, 43 

Nervous disorders in dentition, 179 
Night-dress, 105 
Nipple, fissures of, 67 
Niir o-muriatic acid bath, 104 



Noma (see Gangrenous stomatitis) , 1 39 

pathology and morbid anatomy 
of, 138 

diagnosis of, 139 

prognosis of, 140 

treatment of, 140 
Normal capacity of infant's stomach, 

78 

Nostrils, sharpness of, 22 
Nursing-bottle, 95 

mother's diet, 67 

regularity in, 62 



o. 

Oculo- zygomatic furrows, 22 

GEdema, 112 

Oidium albicans, 142 

Oil inunction for constipation, 275 

Oral pain in second dentition, 170 

Otitis, 151, 178 

Oxaluria, 35 

Oxyuris vermicularis, 312 
egg of, 312 
symptoms of, 318 
treatment of, 320 

Ozaena, 1 79 



p. 

Painful micturition, ^^ 
Palpation of the chest, 54 
Pancreatin, 86-87, 88, 92 
Papillae, 58 

Paracentesis in ascites, 382 
Paralysis, dental, 162 

during dentition, 181 
Parasitic stomatitis (see Thrush), 141 
Parenchymatous nephritis, 43 
Pathology and morbid anatomy of 

noma, 138 
Peptogenic milk, powder, 88 
Peptonization, partial, 87 
Peptonized milk, 86 
Percussion of the chest, 55 
Perforation of the caecum, 291 
Peritoneum, affections of, 364 
Peritonitis, 364 

morbid anatomy of, 364 

etiology of, 365 

symptoms of, 365 



39 2 



INDEX. 



Peritonitis, diagnosis of, 368 

prognosis of, 370 

treatment of, 370 

tubercular, 371 
Parasites, intestinal, 33 
Permanent teeth, 58 

eruption of, 164 
order of eruption, 169 
Perityphlitis (see Typhlitis, p~ri-), 287 
Pertussis, 28 
Petrissage, 116 
Pharyngitis, simple, 183 
Photophobia, 24 
Phthisis, 54 

Physical examination, 39 
Piatt's chloride, 141 
Pneumonia, hypostatic, 238 
Premature weaning, 66 
Process for peptonizing milk, 86 
Prognosis of acute gastric catarrh, 201 

of acute intestinal catarrh, 230 

of amyloid liver, 349 

of ascites, 380 

of cholera infantum, 262 

of chronic entero-colitis, 240 

of chronic gastric catarrh, 206 

of cirrhosis of the liver, 355 

of congestion of the liver, 344 

of dysentery, 265 

of entero-colitis, 253 

of fatty infiltration of the liver, 
346 

of follicular tonsillitis, 188 

of habitual constipation, 274 

of habitual indigestion, 217 

of intussusception, 306 

of mucous disease, 220 

of noma, 140 

of peritonitis, 370 

of simple atrophy, 285 

of syphilitic hepatitis, 351 

of tabes mesenterica, 333 

of thrush, 145 

of tubercular peritonitis, 376 

of typhlitis, 292 

of ulcerative stomatitis, 134 

of worms, 319 
Pseudo hypertrophic paralysis, 123 
Puerile breathing, 53 
Pufhness of eyelids, 22 
Pulse, variations in, 42 
Purpura hemorrhagica, 36 



Questioning the attendants, I 
Quinsy, 190 



Raw beef juice, 92 
Reaction of the urine, ^^ 
Red gum, 154 

Reflex spasm during dentition, 180 
Regimen in acute intestinal catarrh. 
232 

in amyloid liver, 350 

in cholera infantum, 263 

in chronic entero-colitis, 241 

in chronic gastric catarrh, 209 

in dysentery, 266 

in entero-colitis, 254 

in mucous disease, 222 

in simple atrophy, 286 
Renal calculus, 36 

hemorrhage, 35 
Resorcin in entero-colitis, 257 
Respiration, 39 

character of, 40 

expiratory, 41 

inspiratory, 41 
Retention of urine, 37 
Retro-pharyngeal abscess, 197 
symptoms of, 197 
treatment of, 198 
Rheumatism, 47 
Rice pudding, 100 
Rickets, 59, 69, 119 
Rubber shoes, 104 
Rules for feeding, 79 



Saccharated solution of lime, 80, 294 
Salicylate of sodium in entero-colitis, 

257 
Salt-water bath, 104 
Sarcoma of kidney, 36 
Scarlet fever, 59, 128 
Sclerema, 112 
Secondary thrush, 144 
Second dentition, disorders of, 170 

as a cause of mucous disease, 
177 
Secretion of milk, 61 



INDEX. 



393 



Serous effusion in chronic entero- 
colitis, 238 
Shoes, 106 
Simple atrophy, 279 

, morbid anatomy of, 279 
etiology of, 279 
manner of preparing food in, 

281 
symptoms of, 282 
diagnosis of, 284 
prognosis of, 285 
treatment of, 285 
regimen in, 286 
diarrhoea of dentition, 152 
pharyngitis, 183 

anatomical lesion of, 183 
etiology of, 183 
symptoms of, 183 
diagnosis of, 184 
treatment of, 185 
Skin, discoloration of, in jaundice, ^8 
the, 25 

conditions of the, 46 
Sleep, 106 

Sleeping, different characters of, 24 
Sleeping room, 107 
Soda bath, 104 

Softening of the stomach, 212 
Sound cows' milk, 98 
Sour breath, 30 
Spasms during dentition, 161 

inward, 283 
Spec. grav. of breast milk, 72 

cows' milk, 74 
Spinal irritability, 123 
Stationary washstand, 107 
Statistics from the Maternite, in Paris, 

112 
Stercoraceous breath, 31 

vomiting, 303 
Sterilized milk, 88 

rules to be observed in its 

use, 91 
uses of, 91 
Sterilizer, the author's, 89 
Stomach, measurements of infants, 78 
nerve supply of, 165 
softening of, 212 
ulcer of, 211 
Stomatitis, aphthous, 126 
catarrhal, 124 
gangrenous, 136 



Stomatitis, parasitic (see Thrush), 141 

ulcerative, 13 1 
Stools, characters of, 32 
Strippings, 85, 208 
Strophulus during dentition, 154 
Strumous diathesis, 23 
wSubmaxillary gland, enlargement of, 

during second dentition, 177 
Sudden weaning, 66 
vSummer diarrhoea, 248 
Sunstroke, 261 

Superficial catarrh of the tonsils, 186 
Suppurative hepatitis, 357 

report of case, 357 
symptoms of, 357 
diagnosis of, 362 
treatment of, 362 
tonsillitis, 190 

morbid anatomy of, 190 
symptoms of, 191 
diagnosis of, 192 
treatment of, 192 
Symptoms of acute gastric catarrh, 
200 
of acute intestinal catarrh, 229 
of amyloid liver, 348 
of aphthous stomatitis, 127 
of ascaris lumbricoides,3i9 
of ascites, 378 
of cholera infantum, 259 
of chronic entero-colitis, 237 
of chronic gastric catarrh, 204 
of cirrhosis of the liver, 354 
of colic, 270 

of congestion of the liver, 343 
of dysentery, 264 
of entero-colitis, 250 
of fatty infiltration of the liver, 

346 
of follicular tonsillitis, 187 
of mucous disease, 218 
of gangrenous stomatitis, 136 
of habitual constipation, 274 
of habitual indigestion, 215 
of hypertrophy of the tonsils, 

194 
of intussusception, 301 
of oxyuris vermicularis, 318 
of peritonitis, 365 
of retro-pharyngeal abscess, 197 
of septic peritonitis, 368 
of simple atrophy, 282 



33 



394 



JNDEX. 



Symptoms of simple pharyngitis 183 
of suppurative hepatitis, 357 
of suppurative tonsillitis, 191 
of tabes mesenterica, 330 
of taenia, 319 
of thrush, 143 

of tubercular peritonitis, 372 
of tubercular ulceration of the 

intestines, 269 
of typhlitis, 289 
of ulcerative stomatitis, 132 
of ulcer of the stomach, 21 1 
of syphilitic hepatitis, 351 
of worms, 317 
Syphilitic hepatitis, 35 1 

morbid anatomy of, 351 

symptoms of, 351 

diagnosis of, 351 

prognosis of, 351 

treatment of, 352 

T. 

Tabes mesenterica, 329 

morbid anatomy of, 329 

etiology of, 330 

symptoms of, 330 

diagnosis of, 332 

prognosis of, 3^3 

treatment of, 3,34 
Taeniae, 314 

saginata, 314 

e gg° f , 3*5 
solium, 316 

symptoms of, 319 

treatment of, 323 
Tanret's Pelletierine for tapeworm, 326 
Tapotement, 117 
Tarnier's hatching cradle, 1 10 
Taste, loss of, 172 
Taxis in intussusception, 309 
Tears, formation of, 28 

suppression of, 28 
Teeth, children born with, 149 

eruption of the temporary, 148 

milk, 57 

permanent, 58 

premature appearance of, 149 
Teething cough, 178 
Temperature, 43 

of room, 108 

variations in, 44 



Thermometer, clinical, 43 
Throat affections during second denti- 
tion, 172 
Thrombosis of the sinuses of the brain 

during chronic entero- colitis, 238 
Thrush, 141 

morbid appearances of, 142 

etiology of, 142 

symptoms of, 143 

secondary, 144 

diagnosis of, 145 

prognosis of, 145 

treatment of, 146 
Tongue, 58 

in disease, 59 
Tonsillitis, follicular, 187 

suppurative, 190 
Tonsils, excision of, 196 

hypertrophy of, 194 
Tooth rash, 154 
Treatment of acute gastric catarrh, 201 

of acute intestinal catarrh, 231 
"of amyloid liver, 349 

of aphthous stomatitis, 128 

of ascaris lumbricoides, 321 

of ascites, 380 

of catarrhal stomatitis, 125 

of cholera infantum, 262 

of chronic entero-colitis, 241 

of chronic gastric catarrh, 207 

of cirrhosis of the liver, 355 

of colic, 271 

of congestion of the liver, 345 

of convulsions during teething, 
162 

during second dentition, 175 

of dysentery, 265 

of eczema, 157 

of entero colitis, 253 

of fatty infiltration of the liver, 

347 
of fissure of nipple, 68 
of follicular tonsillitis, 189 
of habitual constipation, 274 
of headache during dentition, 180 
of hypertrophy of the tonsils, 195 
of intussusception, 306 
of icterus in older children, 342 
of jaundice, 339 
of mucous disease, 220 
of nasal catarrh, 179 
of noma, 140 



INDEX. 



395 



Treatment of oxyuris vermicularis, 320 
of peritonitis, 370 
of retro-pharyngeal abscess, 198 
of simple atrophy, 285 
of simple pharyngitis, 185 
of superficial ulcers of the tongue, 

173 . ... 

of suppurative hepatitis, 362 

tonsillitis, 192 
of syphilitic hepatitis, 352 
of tabes mesenterica, 334 
of taenia, 323 
of thrush, 146 

of tubercular peritonitis, 376 
of tubercular ulceration of the in- 
testines, 269 
of typhlitis, 292 
of ulcerative stomatitis, 134 
of ulcer of the stomach, 212 
of worms, 320 
Trichocephalus dispar, 314 

egg of, 314 
True intussusception, 297 
Tubercular meningitis, 284 
peritonitis, 371 

morbid anatomy of, 371 
etiology of, 372 
symptoms of, 372 
diagnosis of, 375 
prognosis of, 376 
treatment of, 376 
ulceration of the intestines, 268 
ulceration of the intestines, mor- 
bid anatomy of, 268 
ulceration of the intestines, etiol- 
ogy of, 268 
ulceration of the intestines, symp- 
toms of, 269 
ulceration of the intestines, treat- 
ment of, 269 
Tuberculosis of the liver, 363 
Tuberculous tendency, signs of, 22 
Tumor, faecal, 31 
Typhlitis, 287 

morbid anatomy of, 287 
etiology of, 289 % 

stercoralis, 289 
symptoms of, 289 
diagnosis of, 291 
prognosis of, 292 
treatment of, 292 
Tyrotoxicon, 99 



u. 

Ulceration of the appendix, 291 

of the lungs, 31 
Ulcerative stomatitis, 131 

anatomical lesions of, 131 
etiology of, 131 
symptoms of, 132 
diagnosis of, 134 
prognosis of, 134 
treatment of, 134 
Ulcer of the stomach, 21 1 

symptoms of, 21 1 
treatment of, 212 
Ulcers of the tongue during second 

dentition, 171 
Uraemic poisoning, 31 
Uric acid, 33, 37 
Urine the, 33 

spec. grav. of, 33 
characters of, 33 
daily amount voided, 34 
abnormal ingredients of, 35 
of different diseases, 36 
Urinometer, 74 

Urticaria during dentition, 153 
Uvula the, 58 



V. 

Varicella, 59 
Variola, 128 
Veal broth, 92 

with barley water, 208 
Ventilation, 107 
Vertigo, 319 
Vesicles, herpetic, 26 
Vocal fremitus, 54 
Vomiting, 38 

chronic, 203 

during dentition, 153 

stercoraceous, 303 



w. 

Walking, delay in, 46 

Weak and immature infants, 109 

Weaning, 64 

sudden, 66 

premature, indications for, 66 
Wet-nurs£, feeding by, 69 

proper woman for a, 70 



39^ 



INDEX. 



Wet-nurse, examination of, 70 

diet of, 7 1 
Whey, 81, 207 
Whip worms, 314 
White gum 154 
Whooping cough, 128, 177, 217 
Worms, 311 

mode of entering the body, 312 

symptoms of, 317 






Worms, diagnosis of, 319 
prognosis of, 319 
treatment of, 3 20 



Yawning, 41 
Yellow discoloration 
jaundice, 338 



of the skin in 



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" The brief examination I have given it was so favorable that I 
placed it in the list of text-books recommended in the circular of the 
University Medical College." — Prof, Lewis A. Stimson, m.d., 
37 East 33d Street, New York. 

Price of each Book, Cloth, $3.00; Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 5. ORGANIC CHEMISTRY. 

Or the Chemistry of the Carbon Compounds. By Prof. 
Victor von Richter, University of Breslau. Au- 
thorized translation, from the Fourth German Edition. 
By Edgar F. Smith, m.a., ph.d. ; Prof, of Chemistry 
in University of Pennsylvania; Member of the Chem. 
Socs. of Berlin and Paris. 

" I must say that this standard treatise is here presented in a 
remarkably compendious shape."— y. W. Holland , m.d., Professor 
of Chemistry , Jefferson Medical College , Philadelphia. 

" This work brings the whole matter, in simple, plain language, 
to the student in a clear, comprehensive manner. The whole 
method of the work is one that is more readily grasped than that of 
older and more famed text-books, and we look forward to the time 
when, to a great extent, this work will supersede others, on the 
score of its better adaptation to the wants of both teacher and 
student." — Pharmaceutical Record, 

" Prof, von Richter's work has the merit of being singularly 
clear, well arranged, and for its bulk, comprehensive. Hence, it 
will, as we find it intimated in the preface, prove useful not merely 
as a text-book, but as a manual of reference." — The Chemical 
News, London. 

No. 6. DISEASES OF CHILDREN. 

SECOND EDITION. 

A Manual. By J. F. Goodhart, m.d., Phys. to the 
Evelina Hospital for Children; Asst. Phys. to 
Guy's Hospital, London. Second American Edition. 
Edited and Rearranged by Louis Starr, m.d., Clinical 
Prof, of Dis. of Children in the Hospital of the Univ. 
of Pennsylvania, and Physician to the Children's Hos- 
pital, Phila. Containing many new Prescriptions, a list 
of over 50 Formulae, conforming to the U. S. Pharma- 
copoeia, and Directions for making Artificial Human 
Milk, for the Artificial Digestion of Milk, etc. Illus. 

" The author has avoided the not uncommon error of writing a 
book on general medicine and labeling it ' Diseases of Children,' 
but has steadily kept in view the diseases which seemed to be 
incidental to childhood, or such points in disease as appear to be so 
peculiar to or pronounced m children as to justify insistence upon 
them. * * * A safe and reliable guide, and in many ways 
admirably adapted to the wants of the student and practitioner." — 
American Journal of Medical Science. 

Price of each Book, Cloth, $3.00 ; Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 6. Goodhart and Starr : — Continued. 

" Thoroughly individual, original and earnest, the work ev 
dently of a close observer and an independent thinker, this book, 
though small, as a handbook or compendium is by no means made 
up of bare outlines or standard facts." — The Therapeutic Ga- 
zette. 

'* As it is said of some men, so it might be said of some books, 
that they are 'born to greatness.' This new volume has, we 
believe, a mission, particularly in the hands of the younger 
members of the profession. In these days of prolixity in medical 
literature, it is refreshing to meet with an author who knows both 
what to say and when he has said it. The work of Dr. Goodhart 
(admirably conformed, by Dr. Starr, to meet American require- 
ments) is the nearest approach to clinical teaching without the 
actual presence of clinical material that we have yet seen." — New 
York Medical Record. 

No. 7. PRACTICAL THERAPEUTICS. 

FOURTH EDITION, WITH AN INDEX OF DISEASES. 

Practical Therapeutics, considered with reference to 
Articles of the Materia Medica. Containing, also, an 
Index of Diseases, with a list of the Medicines 
applicable as Remedies. By Edward John Waring, 
m.d., f.r.c.p: Fourth Edition. Rewritten and Re- 
vised by Dudley W. Buxton, m.d., Asst. to the Prof, 
of Medicine at University College Hospital. 

" We wish a copy could be put in the hands of every Student or 
Practitioner in the country. In our estimation, it is the best book 
of the kind ever written." — N. Y. Medical Journal. 

No. 8. MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

NEW, REVISED AND ENLARGED EDITION. 

By John J. Reese, m.d., Professor of Medical Jurispru- 
dence and Toxicology in the University of Pennsyl- 
vania ; President of the Medical Jurisprudence Society 
of Phila. ; 2d Edition, Revised and Enlarged. 

" This admirable text-book." — Amer.Jour. of Med. Sciences. 

u We lay this volume aside, after a careful perusal of its pages, 
with the profound impression that it should be in the hands of every 

doctor and lawyer. It fully meets the wants of all students 

He has succeeded in admirably condensing into a handy volume all 
the essential points." — Cincinnati Lancet and Clinic. 

Price of each Book, Cloth, $3,00 ; Leather, $3.50. 



8 STUDENTS' TEXT-BOOKS AND MANUALS. 

Children: — Continued. 

Meigs and Pepper. The Diseases of Children. Seventh 
Edition. 8vo. Cloth, 5.00; Leather, 6.00 

Starr. Diseases of the Digestive Organs in Infancy and 
Childhood. With chapters on the Investigation of Disease, 
and on the General Management of Children. By Louis Starr, 
m.d., Clinical Professor of Diseases of Children in the Univer- 
sity of Pennsylvania. Illus. Second Edition. In Press. 

DENTISTRY. 

Fillebrown. Operative Dentistry. 330 Illus. Cloth, 2.50 

Flagg's Plastics and Plastic Filling. 3d Ed. Preparing. 
Gorgas. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. Third Edition. Cloth, 3.50 

Harris. Principles and Practice of Dentistry. Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery 
and Mechanism. Twelfth Edition. Revised and enlarged by 
Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 
Richardson's Mechanical Dentistry. Fifth Edition. 569 
Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 

Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 
Stocken's Dental Materia Medica. Third Edition. Cloth, 2.50 
Taft's Operative Dentistry. Dental Students and Practitioners. 
Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 
Talbot. Irregularities of the Teeth, and their Treatment. 
Illustrated. 8vo. Second Edition. Cloth, 3.00 

Tomes' Dental Anatomy. Third Ed. 191 Illus. Cloth, 4.00 
Tomes' Dental Surgery. 3d Edition. Revised. 292 Illus. 
772 Pages. Cloth, 5.00 

Warren. Compend of Dental Pathology and Dental Medi- 
cine. Illustrated. Cloth, 1. 00; Interleaved, 1.25 

DICTIONARIES. 

Gould's New Medical Dictionary. Containing the Definition 
and Pronunciation of all words in Medicine, with many useful 
Tables etc. ^ Dark Leather, 3.25 ; y 2 Mor., Thumb Index 4.25 

Cleaveland's Pronouncing Pocket Medical Lexicon. 31st 
Edition. Giving correct Pronunciation and Definition. Very 
small pocket size. Cloth, red edges .75 j pocket-book style, 1.00 

LfOngley 's Pocket Dictionary. The Student's Medical Lexicon, 
giving Definition and Pronunciation of all Terms used in Medi- 
cine, with an Appendix giving Poisons and Their Antidotes, 
Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
24rao. Cloth, 1. 00; pocket-book style, 1.25 

• See Pages 2 to 5 for list of Students* Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 9 

EYE. 

Arlt. Diseases of the Eye. Including those of the Conjunc- 
tiva, Cornea, Sclerotic, Iris and Ciliary Body. By Prof. Von 
Arlt. Translated by Dr. Lyman Ware. Illus. 8vo. Cloth, 2.50 

Hartridge on Refraction. 4th Ed. Cloth, 2.00 

Meyer. Diseases of the Eye. A complete Manual for Stu- 
dents and Physicians. 270 Illustrations and two Colored Plates. 
8vo. Cloth, 4.50; Leather, 5.50 

Fox and Gould. Compend of Diseases of the Eye and 
Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. 

Cloth, 1. 00 ; Interleaved for Notes, 1.25 

ELECTRICITY. 

Mason's Compend of Medical and Surgical Electricity. 
With numerous Illustrations. i2mo. « Cloth, 1.00 

HYGIENE. 

Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- 
larged. Illustrated. 8vo. Cloth, 4.50 

Parkes' (L. C.) Manual of Hygiene and Public Health. 
i2mo. Cloth, 2.50 

Wilson's Handbook of Hygiene and Sanitary Science. 
Sixth Edition. Revised and Illustrated. Cloth, 2.75 

MATERIA MEDICA AND THERAPEUTICS. 

Potter's Compend of Materia Medica, Therapeutics and 

Prescription Writing. Fifth Edition, revised and improved. 

Cloth, 1.00; Interleaved for Notes, 1.25 

Biddle's Materia Medica. Eleventh Edition. By the late 
John B. Biddle, m.d., Professor of Materia Medica in Jefferson 
Medical College, Philadelphia. Revised, and rewritten, by 
Clement Biddle, m.d., Assist. Surgeon, U. S. N., assisted by 
Henry Morris, m.d. 8vo., illustrated. Cloth, 4.25; Leather, 5.00 

Headland's Action of Medicines. 9th Ed. 8vo. Cloth, 3.00 

Potter. Materia Medica, Pharmacy and Therapeutics. 
Including Action of Medicines, Special Therapeutics, Pharma- 
cology, etc. Second Edition. Cloth, 4.00; Leather, 5.00 

Starr, Walker and Powell. Synopsis of Physiological 
Action of Medicines, based upon Prof. H. C. Wood's " Materia 
Medica and Therapeutics/' 3d Ed. Enlarged. Cloth, .75 

Waring. Therapeutics. With an Index of Diseases and 
Remedies. 4th Edition. Revised. Cloth, 3.00 ; Leather, 3.50 
See pages 14 and ij for list of ? Quiz- Compends ? 



10 STUDENTS' TEXT-BOOKS AND MANUALS. 

MEDICAL JURISPRUDENCE. 

Reese. A Text-book of Medical Jurisprudence and Toxi- 
cology. By John J. Reese, m.d., Professor of Medical Juris- 
prudence and Toxicology in the Medical Department of the 
University of Pennsylvania; President of the Medical Juris- 
prudence Society of Philadelphia ; Physician to St. Joseph's 
Hospital ; Corresponding Member of The New York Medico- 
legal Society. 2d Edition. Cloth, 3.00; Leather, 3.50 

Woodman and Tidy's Medical Jurisprudence and Toxi- 
cology. Chromo-Lithographic Plates and 116 Wood engravings. 

Cloth, 7.50; Leather, 8.50 

OBSTETRICS AND GYNECOLOGY. 

Byford. Diseases of Women. The Practice of Medicine and 
Surgery, as applied to the Diseases and Accidents Incident to 
Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology 
in Rush Medical College and of Obstetrics in the Woman's Med- 
ical College, etc., and Henry T. Byford, m.d., Surgeon to the 
Woman's Hospital of Chicago ; Gynaecologist to St. Luke's 
Hospital, etc. Fourth Edition. Revised, Rewritten and En- 
larged. With 306 Illustrations, over 100 of which are original. 
Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 

Cazeaux and Tarnier's Midwifery. "With Appendix, by 
Munde. The Theory and Practice of Obstetrics ; including the 
Diseases of Pregnancy and Parturition, Obstetrical Operations, 
etc. By P. Cazeaux. Remodeled and rearranged, with revi- 
sions and additions, by S. Tarnier, m.d., Professor of Obstetrics 
and Diseases of Women and Children in the Faculty of Medicine 
of Paris. Eighth American, from the Eighth French and First 
Italian Edition. Edited by Robert J. Hess, m.d., Physician to 
the Northern Dispensary, Philadelphia, with an appendix by 
Paul F. Munde, m.d., Professor of Gynaecology at the N. Y. 
Polyclinic. Illustrated by Chromo-Lithographs, Lithographs, 
and other Full-page Plates, seven of which are beautifully colored, 
and numerous Wood Engravings. Students' Edition. One 
Vol., 8vo. Cloth, 5.00; Leather, 6.00 

Lewers' Diseases of Women. A Practical Text-Book. 139 
Illustrations. Second Edition. Cloth, 2.50 

Parvin's Winckel's Diseases of Women. Second Edition. 

Including a Section on Diseases of the Bladder and Urethra. 
. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 

Morris. Compend of Gynaecology. Illustrated. Cloth, 1.00 
Winckel's Obstetrics. A Text-book on Midwifery, includ- 
ing the Diseases of Childbed. By Dr. F. Winckel, Professor 
of Gynaecology, and Director of the Royal University Clinic for 
Women, in Munich. Authorized Translation, by J. Clifton 
Edgar, m.d., Lecturer on Obstetrics, University Medical Col- 
lege, New York, with nearly 200 handsome illustrations, the 
majority of which are original with this work. Octavo. 

Cloth, 6.00; Leather, 7.00 

Landis' Compend of Obstetrics. Illustrated. 4th edition, 
enlarged. Cloth, 1.00; Interleaved for Notes, 1.25 

J%$°~ See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 11 

Obstetrics and Gynecology : — Continued. 
Galabin's Midwifery. By A. Lewis Galabin, m.d., f.r.c.p. 
227 Illustrations. Seepages. Cloth, 3.00; Leather, 3.50 

Glisan's Modern Midwifery. 2d Edition. Cloth, 3.00 

Rigby's Obstetric Memoranda. 4th Edition. Cloth, .50 

Meadows' Manual of Midwifery. Including the Signs and 
Symptoms of Pregnancy, Obstetric Operations, Diseases of the 
Puerperal State, etc. 145 Illustrations. 494 pages. Cloth, 2.00 

Swayne's Obstetric Aphorisms. For the use of Students 
commencing Midwifery Practice. 8th Ed. i2mo. Cloth, 1.25 

PATHOLOGY. HISTOLOGY. BIOLOGY. 

Bowlby. Surgical Pathology and Morbid Anatomy, for 
Students. 135 Illustrations. i2mo. Cloth, 2.00 

Davis' Elementary Biology. Illustrated. Cloth, 4.00 

Gilliam's Essentials of Pathology. A Handbook for Students. 
47 Illustrations. i2mo. Cloth, 2.00 

*#* The object of this book is to unfold to the beginner the funda- 
mentals of pathology in a plain, practical way, and by bringing 
them within easy comprehension to increase his interest in the study 
of the subject. 

Gibbes' Practical Histology and Pathology. Third Edition. 
Enlarged. i2mo. Cloth, 1.75 

Virchow's Post-Mortem Examinations. 2d Ed. Cloth, 1.00 

PHYSIOLOGY. 

Yeo's Physiology. Fourth Edition. The most Popular Stu- 
dents' Book. By Gerald F. Yeo, m.d., f.r.c.s., Professor of 
Physiology in King's College, London. Small Octavo. 758 
pages. 321 carefully printed Illustrations. With a Full 
Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 

Brubaker's Compend of Physiology. Illustrated. Fifth 
Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 

Stirling. Practical Physiology, including Chemical and Ex- 
perimental Physiology. 142 Illustrations. Cloth, 2.25 

Kirke's Physiology. New 12th Ed. Thoroughly Revised and 
Enlarged. 502 Illustrations. Cloth, 4.00; Leather, 5.00 

Landois' Human Physiology. Including Histology and Micro- 
scopical Anatomy, and with special reference to Practical Medi- 
cine. Third Edition. Translated and Edited by Prof. Stirling. 
692 Illustrations. Cloth, 6.50; Leather, 7.50 

" With this Text-book at his command, no student could fail in 

his examination." — Lancet, 

Sanderson's Physiological Laboratory. Being Practical Ex- 
ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 

Tyson's Cell Doctrine. Its History and Present State. Illus- 
trated. Second Edition. Cloth, 2.00 

See pages 14 and 13 for list of ? Quiz-Compends f 



12 STUDENTS' TEXT-BOOKS AND MANUALS. 



PRACTICE. 

Taylor. Practice of Medicine. A Manual. By Frederick 
Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's 
Hospital, London ; Physician to Evelina Hospital for Sick Chil- 
dren, and Examiner in Materia Medica and Pharmaceutical 
Chemistry, University of London. Cloth, 4.00 

Roberts' Practice. New Revised Edition. A Handbook 
of the Theory and Practice of Medicine. By Frederick T. 
Roberts, m.d. ; m.r.c.p., Professor of Clinical Medicine and 
Therapeutics in University College Hospital, London. Seventh 
Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 

Hughes. Compend of the Practice of Medicine. 4th Edi- 
tion. Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 

Part i. — Continued, Eruptive and Periodical Fevers, Diseases 
of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
Kidneys, etc., and General Diseases, etc. 

Part ii. — Diseases of the Respiratory System, Circulatory 
System and Nervous System ; Diseases of the Blood, etc. 

Physician's Edition. Fourth Edition. Including a Section 
on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 

From John A. Robinson, M.D., Assistant to Chair of Clinical 
Medicine , now Lecturer on Materia Medica, Rush Medical Col- 
lege, Chicago. 
" Meets with my hearty approbation as a substitute for the 

ordinary note books almost universally used by medical students. 

It is concise, accurate, well arranged and lucid, . . . just the 

thing for students to use while studying physical diagnosis and the 

more practical departments of medicine." 

PRESCRIPTION BOOKS. 

Wythe's Dose and Symptom Book. Containing the Doses 
and Uses of all the principal Articles of the Materia Medica, etc. 
Seventeenth Edition. Completely Revised and Rewritten. Just 
Ready. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 

Pereira's Physician's Prescription Book. Containing Lists 
of Terms, Phrases, Contractions and Abbreviations used in 
Prescriptions Explanatory Notes, Grammatical Construction of 
Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
Sixteenth Edition. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 

PHARMACY. 
Stewart's Compend of Pharmacy. Based upon Remington's 
Text-Book of Pharmacy. Third Edition, Revised. With new 
Tables, Index, Etc. Cloth, 1.00; Interleaved for Notes, 1.25 

Robinson. Latin Grammar of Pharmacy and Medicine. 
By H. D. Robinson, ph.d., Professor of Latin Language and 
Literature, University of Kansas, Lawrence. With an Intro- 
duction by L. E. Say re, ph.g., Professor of Pharmacy in, and 
Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. 

Cloth, 2.00 

SKIN DISEASES. 

Anderson, (McCall) Skin Diseases. A complete Text-Book, 
with Colored Plates and numerous Wood Engravings. 8vo. 

Cloth, 4.50; Leather, 5.50 
£^~ See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 13 

Skin Diseases : — Continued. 

Van Harlingen on Skin Diseases. A Handbook of the Dis- 
eases of the Skin, their Diagnosis and Treatment (arranged alpha- 
betically). By Arthur Van Harlingen, m.d., Clinical Lecturer 
on Dermatology, Jefferson Medical College ; Prof, of Diseases of 
the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. 
With colored and other plates and illustrations. i2mo. Cloth, 2.50 

Bulkley. The Skin in Health and Disease. By L. Duncan 
Bulkley, Physician to the N. Y. Hospital. Illus. ' Cloth, .50 

SURGERY AND BANDAGING. 

Jacobson. Operations in Surgery. A Systematic Handbook 
for Physicians, Students and Hospital Surgeons. By W. H. A. 
Jacobson, b a., Oxon. f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- 
pital ; Surgeon at Royal Hospital for Children and Women, etc. 
199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 
Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 
Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 

Horwitz's Compend of Surgery, Minor Surgery and 
Bandaging, Amputations, Fractures, Dislocations, Surgical 
Diseases, and the Latest Antiseptic Rules, etc., with Differential 
Diagnosis and Treatment. By Orville Hokwitz, b.s., m.d., 
Demonstrator of Surgery, Jefferson Medical College. 4th edition. 
Enlarged and Rearranged. 136 Illustrations and 84 Formulas. 
i2mo. Cloth, 1.00; Interleaved for the addition of Notes, 1.25 
%* The new Section on Bandaging and Surgical Dressings, con- 
sists of 32 Pages and 41 Illustrations. Every Bandage of any 
importance is figured. This, with the Section on Ligation of 
Arteries, forms an ample Text-book for the Surgical Laboratory. 

Walsham. Manual of Practical Surgery. For Students and 
Physicians. By Wm. J. Walsham, m.d., f.r.c.s., Asst. Surg, 
to, and Dem. of Practical Surg, in, St. Bartholomew's Hospital, 
Surgeon to Metropolitan Free Hospital, London. With 236 
Engravings. See Page 2. Cloth, 3.00; Leather, 3.50 

URINE, URINARY ORGANS, ETC. 

Holland. The Urine, and Common Poisons and The 
Milk. Chemical and Microscopical, for Laboratory Use. Illus- 
trated. Third Edition. i2mo. Interleaved. Cloth, 1.00 

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- 
trations. i2mo. 572 pages. Cloth, 2.75 

Marshall and Smith. On the Urine. The Chemical Analysis of 
the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. 
of Penna; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 

Thompson. Diseases of the Urinary Organs. Eighth 
London Edition. Illustrated. Cloth, 3.50 

Tyson. On the Urine. A Practical Guide to the Examination 
of Urine. With Colored Plates and Wood Engravings. 6th Ed. 
Enlarged. i2mo. Cloth, 1.50 

Van Niiys, Urine Analysis. Illus. Cloth, 2.00 

VENEREAL DISEASES. 

Hill and Cooper. Student's Manual of Venereal Diseases, 
with Formulae. Fourth Edition. i2mo. Cloth, 1.00 

4®=* See pages 14 and 13 for list of ? Quiz- Commends f 



NEW AND REVISED EDITIONS. 

PQUIZ-COMPENDS? 

The Best Compends for Students' Use 
in the Quiz Class, and when Pre- 
paring for Examinations. 

Compiled in accordance with the latest teachings of promi- 
nent lecturers and the most popular Text-books. 
They form a most complete, practical and exhaustive 
set of manuals, containing information nowhere else col- 
lected in such a condensed, practical shape. Thoroughly 
up to the times in every respect, containing many new 
prescriptions and formulae, and over two hundred and 
fifty illustrations, many of which have been drawn and 
engraved specially for this series. The authors have had 
large experience as quiz-masters and attaches of colleges, 
with exceptional opportunities for noting the most recent 
advances and methods. 

Cloth, each $1.00. Interleaved for Notes, $1.25. 

No. 1. HUMAN ANATOMY, «' Based upon Gray." Fifth 
Enlarged Edition, including Visceral Anatomy, formerly 
published separately. 16 Lithograph Plates, New 
Tables and 117 other Illustrations. By Samuel O. L. 
Potter, m.a., m.d., late A. A. Surgeon U. S. Army. Professor 
of Practice, Cooper Medical College, San Francisco. 

Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- 
tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical 
Medicine in Jefferson Medical College, Philadelphia. In two parts. 

Part I. — Continued, Eruptive and Periodical Fevers, Diseases 
of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
Kidneys, etc. (including Tests for Urine), General Diseases, etc. 

Part II. — Diseases of the Respiratory System (including Phy- 
sical Diagnosis), Circulatory System and Nervous System; Dis- 
eases of the Blood, etc. 

*#* These little books can be regarded as a full set of notes upon 
the Practice of Medicine, containing the Synonyms, Definitions, 
Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each 
disease, and including a number of prescriptions hitherto unpub- 
lished. 

No. 4. PHYSIOLOGY, including Embryology. Fifth 
Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, 
Penn'a. College of Dental Surgery ; Demonstrator of Physiology 
in Jefferson Medical College, Philadelphia. Revised, Enlarged 
and Illustrated. 

No. 5. OBSTETRICS. Illustrated. Fourth Edition. By 
Henry G. Landis, m.d.. Prof, of Obstetrics and Diseases of 
Women, in Starling Medical College, Columbus, O. Revised 
Edition. New Illustrations. 



BLAKISTON'S ? QUIZ-COMPENDS ? 

No. 6. MATERIA MEDICA, THERAPEUTICS AND 
PRESCRIPTION WRITING. Fifth Revised Edition. 

With especial Reference to the Physiological Action of Drugs, 
and a complete article on Prescription Writing. Based on the 
Last Revision of the U. S. Pharmacopoeia, and including many 
unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., 
late A. A. Surg. U. S. Army; Prof, of Practice, Cooper Medical 
College, San Francisco. Improved and Enlarged, with Index. 
No. 7. GYNECOLOGY. A Compend of Diseases of Women. 
By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson 
Medical College, Philadelphia. 45 Illustrations. 

No. 8. DISEASES OF THE EYE AND REFRACTION, 

including Treatment and Surgery. By L. Webster Fox, m.d., 
Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- 
ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 
Formulae. Second Enlarged and Improved Edition. Index. 

No. 9. SURGERY, Minor Surgery and Bandaging. Illus- 
trated. Fourth Edition. Including Fractures, Wounds, 
Dislocations, Sprains, Amputations and other operations ; Inflam- 
mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. 
Diseases of the Spine, Ear, Bladder, Testicles, Anus, and 
other Surgical Diseases. By Orville Horwitz, a.m., m.d., 
Demonstrator of Surgery, Jefferson Medical College. Revised 
and Enlarged. 84 Formulae and 136 Illustrations. 

No. 10. CHEMISTRY. Inorganic and Organic. For Medical 
and Dental Students. Including Urinary Analysis and Medical 
Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in 
Penn'a College of Dental Surgery, Phila. Third Edition, Revised 
and Rewritten, with Index. 

No. 11. PHARMACY. Based upon " Remington's Text-book 
of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master 
at Philadelphia College of Pharmacy. Third Edition, Revised. 

No. 12. VETERINARY ANATOMY AND PHYSIOL- 
OGY. 29 Illustrations. By Wm. R. Ballou, m.d., Prof, of 
Equine Anatomy at N. Y. College of Veterinary Surgeons. 

No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- 
CINE. Containing all the most noteworthy points of interest 
to the Dental student. By Geo. W. Warren, d.d.s., Clinical 
Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. 

No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. 
Hatfield, Prof, of Diseases of Children, Chicago Medical 
College. Colored Plate. 

Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. 



These books are constantly revised to keep up with 
the latest teachings and discoveries, so that they contain 
all the new methods and principles. No series of books 
are so complete in detail, concise in language, or so well 
printed and bound. Each one forms a complete set of 
notes upon the subject under consideration. 

Illustrated Descriptive Circular Free. 



JUST PUBLISHED. 



GOULD'S NEW 

Medical Dictionary 




COMPACT. 

CONCISE. 

PRACTICAL. 

ACCURATE. 

COMPREHENSIVE 

UP TO DATE. 



It contains Tables of the Arteries, Bacilli, Gan 

glia, Leucomaines, Micrococci, Muscles, 

Nerves, Plexuses, Ptomaines, etc., 

etc., that will be found of great 

use to the student. 



Small octavo, 520 pages, Half-Dark Leather, . $3.25 
With Thumb Index, Half Morocco, marbled edges, 4.25 



From J. M. DaCOSTA, M. D., Professor of Practice and 
Clinical Medicine, Jefferson Medical College, Philadelphia. 

"I find it an excellent work, doing credit to the learning and 
discrimination of the author.'* 



